state of the art of treating adolescent substance use disorders: course, treatment system, and...

State of the Art of Treating Adolescent Substance Use Disorders: Course, Treatment System, and Evidence Based Practices

Michael Dennis, Ph.D.

Chestnut Health Systems,

Bloomington, ILPresentation at “2005 State Adolescent Coordinators (SAC) Grantee Orientation Meeting”, November 28-30, 2005, Baltimore, MD. 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]

2

1. Epidemiological Course : Examining the prevalence, course, and consequences of adolescent substance use and co-occurring disorders and the unmet need for treatment

2. The Treatment System: Summarizing major trends in the adolescent treatment system and the variability by state

3. Evidence Based Practice: Highlighting what it takes to move the field towards evidenced based practice related to assessment, treatment, program evaluation and planning

4. Treatment Effectiveness: Findings from four recent treatment outcome studies.

Four Parts of this Presentation

3

Part 1 Epidemiological Course: Examining the prevalence, course, and consequences of adolescent substance

use and co-occurring disorders and the unmet need for treatment

4

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

5

Problems Vary by Age

Source: 2002 NSDUH and Dennis et al forthcoming

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

No Alcohol or Drug Use

Light Alcohol Use Only

Any Infrequent Drug Use

Regular AOD Use

Abuse

Dependence

NSDUH Age Groups

Severity CategoryAdolescent

OnsetRemission

Increasing rate of non-

users

6

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

7

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

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

3945

63

71

3734

51

62

30

23

41

48

0

10

20

30

40

50

60

70

80

90

100

Tobacco, OR=1.3*,Pop.=151,442,082

Alcohol, OR=1.9*,Pop.=176,188,916

Marijuana, OR=1.5*,Pop.=71,704,012

Other, OR=1.5*, Pop.=38,997,916

% w

ith

1+ P

ast Y

ear

Sym

ptom

s

Under Age 15

Aged 15-17

Aged 18 or older

Tobacco: Pop.=151,442,082

OR=1.49*

Alcohol: Pop.=176,188,916

OR=2.74*

* p<.05

Marijuana:Pop.=71,704,012

OR=2.45*

Other Drugs:Pop.=38,997,916

OR=2.65*

8

Substance Use Careers Last for Decades C

um

ula

tive

Su

rviv

al

Years from first use to 1+ years abstinence302520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

Median of 27 years from

first use to 1+ years

abstinence

Source: Dennis et al., 2005

9

Substance Use Careers are Longer the Younger the Age of First Use

Cu

mu

lati

ve S

urv

ival

Years from first use to 1+ years abstinence

under 15*

21+

15-20*

Age of 1st UseGroups

* p<.05 (different from 21+)

302520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0


10

Substance Use Careers are Shorter the Sooner People Get to Treatment

Cu

mu

lati

ve S

urv

ival

20+

0-9*

10-19*

Year to 1st TxGroups

302520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

* p<.05 (different from 20+)Source: Dennis et al., 2005

Years from first use to 1+ years abstinence

11

Treatment Careers Last for Years C

um

ula

tive

Su

rviv

al

Years from first Tx to 1+ years abstinence2520151050

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

Median of 3 to 4 episodes of treatment over 9 years


12

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

13

Importance of Perceived Risk

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

Mar

ijua

na

Use

Ris

k &

Ava

ilab

ilit

y

14

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.

15 Source: Dennis and McGeary (1999) and 1997 NHSDA

Substance Use in the Community

16

Consequences of Substance Use

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

17

Need for Treatment (% of 24,753,586 Adolescents in the U.S. Household Population)

Source: NSDUH and TEDS (see state level estimates in appendix)

8.9%

0.7%

0.6%

5.7%

8.1%

11.5%

10.7%

14.9%

17.8%

0% 5% 10%

15%

20%

25%

Tobacco

Alcohol

Alcohol Binge

Any Drug Use

Marijuana Use

Any Non-Marijuana Drug Use

Past Year AOD Dependence or Abuse

Any Treatment (From NHSDA)

Public Treatment (From TEDS)

--

----

--P

ast M

onth

Use

----

--

Less than 1 in 10 getting treatment

88% of adolescents are treated in the

public system

18

Adolescent AOD Dependence/Abuse

Prevalence6.0 to 8.4%8.5 to 9.0%9.1 to 9.9%10.0 to 14.6%U.S.Avg.=8.9%SAC Grantee

Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf ) and Kilpatrick et al, 2000.

Up 27% from 7% in 1995

19

Unmet Treatment Need Adolescent (% of AOD Dependence/Abuse without any private/public treatment)

Prevalence82.4 to 90.1%90.2 to 92.3%92.4 to 94.2%94.3 to 98.0%U.S.Avg.=92.2%SAC Grantee

Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf )

9 in 10 Untreated

20

Summary Points on Epidemiological Course

Consequences go up as severity increases from use to multiple substance use, abuse, and dependence.

Substance use disorders typically on-set during adolescence and last for decades.

The earlier the age of onset, the longer the course of substance use

The earlier treatment is received, the shorter the course of substance use

Marijuana has become the leading substance problem Less than 1 in 10 adolescents with substance abuse or

dependence problems receive treatment Over 88% are treated in the public system

21

Part 2 The Treatment System: Summarizing major trends in the

adolescent treatment system and the variability by state

22

Adolescent Treatment Admissions have increased by 61% over the past decade

Source: Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS)http://www.samhsa.gov/oas/dasis.htm

61% increase from95,271 in 1993

to 153,251 in 2003

23

Change in Public Sector Admissions (%=(2003-1993)/1993)

ChangeNot available-96 to -7%-8 to +33%+34 to +116%+117 to +337%U.S.Avg.=+61%SAC Grantee

Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health (DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf )

Both Cause &

Consequence

24

Change in Focal Substances*

Source: Treatment Episode Data Set (TEDS) 1993-2003.

Marijuana and Alcohol

Most Common

Methamphetamines & Opiates Rare but

Growing Fast

Most other drugs admissions grew

slower than expected

61% growth

253%

310%

46%

138%

-66%

36%

-56%

44%

19%

111%

0

25,000

50,000

75,000

100,000

125,000

150,000

Alc

ohol

Mar

ijua

na/H

ash

Coc

aine

/Cra

ck

Her

oin/

Opi

ates

Hal

luci

noge

ns

Met

ham

phet

amin

es

Oth

erA

mph

etam

ines

Sti

mul

ants

Inha

lant

s

Oth

er\e

-200%

-100%

0%

100%

200%

300%

400%

1993

2003

Change

*TEDS Primary, Secondary or Tertiary problem

25

0%

20%

40%

60%

80%

100%

Alc

ohol

Mar

ijuan

a/H

ash

Coc

aine

/ Cra

ck

Her

oin/

Opi

ates

Hal

luci

noge

ns

Met

h-am

phet

amin

es

Oth

erA

mph

etam

ines

Stim

ulan

ts

Inha

lant

s

Oth

er\e

0%

20%

40%

60%

80%

100%

Prevalence of Focal Problems Vary by State


Methamphetamine, Heroin/Opiate, and Cocaine problems common in about 25% of

states – but under 10% in most states

Methamphetamine 20% or higher in

AZ, CA,ID,MN,NV,WACocaine 20% or

higher in DE & TX

Opiates 20% or higher in MA & NM

Other Amphetamines 20% or higher in OR

26

41%

37%

12%

37%

114%

115%

5%

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

Juve

nile

Jus

tice

Sch

ool

Sel

f/F

amil

y

Oth

erC

omm

unit

y

Oth

er S

A T

xA

genc

y

Oth

er H

ealt

hC

are

Em

ploy

ee/E

AP

0%

20%

40%

60%

80%

100%

120%

140%

1993

2003

Change

Change in Referral Sources


JJ referrals have doubled, are 53% of 2003 admissions and

driving growth

61% growth

Other sources of Referral have grown, but less than expected

27

Change in Level of Care


61% growth

19%

30%

66%

56%

208%

0

25,000

50,000

75,000

100,000

125,000

150,000

Outpatient IntensiveOutpatient

Detox Short-termResidential

Long-termResidential

-200%

-100%

0%

100%

200%

300%

400%

1993

2003

Change

82% of Adolescents are treated in

Outpatient Settings

IOP has had the fastest growth

Residential has grown, but slower than expected

28

Severity Goes up with Level of Care


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Weekly useat intake

First usedunder age 15

Dependence Prior Treatment

Case Mix Index (Avg)

Outpatient Intensive Outpatient DetoxificationLong-term Residential Short-term Residential

STR: Higher on

Dependence

Baseline Severity Goes up with Level

of CareDetox: Higher on Use

Detox: Higher on Use, but lower on prior tx

29

Other Characteristics

70%

58%

19%

17%

6%

83%

63%

57%

16%

22%

2%

1%

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

Male

Caucasian

African American

Hispanic

Other

15 to 17 years old

9 to 11 yrs education

Student

Employed

Psychological Problems

Pregnant at Admission

Homeless/Runaway


These numbers are artificially low

because of how they are measured

System dominated by male, white,

15 to 17 year olds

30

Most Lack of Standardized Assessment for…

Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment

Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidality)

Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime)

HIV risk behaviors (needle use, sexual risk, victimization)

Child maltreatment (physical, sexual, emotional)

31

Median Length of Stay is only 50 days

Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

0 30 60 90

Outpatient(37,048 discharges)

IOP(10,292 discharges)

Detox(3,185 discharges)

STR(5,152 discharges)

LTR(5,476 discharges)

Total(61,153 discharges)

Lev

el o

f C

are

Median Length of Stay

50 days

49 days

46 days

59 days

21 days

3 days

Less than 25% stay the

90 days or longer time

recommended by NIDA

Researchers

32

53% Have Unfavorable Discharges

Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

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

Outpatient(37,048 discharges)

IOP(10,292 discharges)

Detox(3,185 discharges)

STR(5,152 discharges)

LTR(5,476 discharges)

Total(61,153 discharges)

Completed Transferred ASA/ Drop out AD/Terminated

Despite being widely recommended, only 10% step down after intensive treatment

33

Summary of Problems in the Treatment System

The public systems is changing size, referral source, and focus – often in different directions by state

Major problems are not reliably assessed (if at all) Less than 50% stay 50 days (~7 weeks) Less the 25% stay the 3 months recommended by

NIDA researchers Less than half have positive discharges After intensive treatment, less than 10% step down

to outpatient care While JJ involvement is common, little is known

about the rate of initiation after detention

34

Part 3 Evidence Based Practice: Highlighting what it takes to move the field towards evidenced based practice

related to assessment, treatment, program evaluation and planning

35

The field is increasingly facing demands from payers, policymakers, and the public at large for “evidence-based practices (EBP)” which can reliably produce practical and cost-effective interventions, therapies and medications that will

– reduce risks for initiating drug use among those not yet using, – reduce substance use and its negative consequences among those who are

abusing or dependent, and– reduce the likelihood of relapse for those who are recovering

NIDA Blue Ribbon Panel on Health Services Research (see www.nida.nih.gov )

Context

http://www.nida.nih.gov/

36

Accumulating evidence indicates that most of the theories and approaches that are used within the community of practitioners are unsupported by empirical evidence of effects

Various lists of 70 or so “proven” empirically supported therapies (ESTs) have proven to be relatively infeasible because they have rarely been compared with each other and generally have not been tested with the clinically diverse samples found in community based settings

Need for a new method of integrating scientific evidence and the realities of practice is called for.

Source: Beutler, 2000

General Behavioral Health Practice

37

People with multiple substance use and multiple co-occurring problems are the norm of severity in practice, but are often excluded from research

Individualization of treatment content/duration is the norm in practice, but research based protocols typically involves fixed components/length that are not as appropriate for heterogeneous problems

No treatment is not considered a ethical or significant option, practitioner’s are more interested in identifying which of several treatments to use for a given type of patient – but few such studies have been done

When research practices have been identified, they are often not adopted because practitioner’s often lack the appropriate materials, training and resources to know when or how to implement them

Problems and Barriers in SA Tx

38

Randomized Clinical Trials (RCT) are to Evidence Based Practice (EBP) like Self-reports are to Diagnosis

They are only as good as the questions asked (and then only if done in a reliable/valid way)

They are an efficient and logical place to start But they can be limited or biased and need to be

combined with other information Just because the person does not know something

(or the RCT has not be done), does not mean it is not so

Synthesizing them with other information usually makes them better

39

So what does it mean to move the field towards Evidence Based Practice (EBP)?

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, and long term program planning

Introducing explicit intervention protocols that are– Targeted at specific problems/subgroups and outcomes– Having explicit quality assurance procedures to cause adherence

at the individual level and implementation at the program level

Having the ability to evaluate performance and outcomes – For the same program over time, – Relative to other interventions

40

Reoccurring Themes in the Examples…

Severity and specificity of problem subgroup Manualized and replicable assessment and

treatment protocols Relative strength of intervention for a specific

problem Adherence and implementation of intervention Evaluation of outcomes targeted by the

intervention (a.k.a., logic modeling)

41

The Current Renaissance of Adolescent Treatment Research

Feature 1930-1997 1997-2005

Tx Studies* 16 Over 200

Random/Quasi 9 44

Tx Manuals* 0 30+

QA/Adherence Rare Common

Std Assessment* Rare Common

Participation Rates Under 50% Over 80%

Follow-up Rates 40-50% 85-95%

Methods Descriptive/Simple More Advanced

Economic Some Cost Cost, CEA, BCA

* Published and publicly available

42

Adolescent Treatment Research Currently Being Published 1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of Adol. (DATOS-A) 1995-1997 Drug Abuse Treatment Outcome Study (DOMS) 1997-2000 CSAT’s Cannabis Youth Treatment (CYT) experiments 1998-2003 NIAAA/CSAT’s 15 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 14 individual research grants and CTN studies 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 38 Effective Adolescent Treatment (EAT) 2004-2007 NIAAA/CSAT’s study of diffusion of innovation 2004-2009 CSAT 22 Young Offender Re-entry Programs (YORP) 2005-2008 CSAT 20 Juvenile Drug Court (JDC) 2005-2008 CSAT 16 State Adolescent Coordinator (SAC) grants

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

43

Number of GAIN Sites

Adolescent and Adult Treatment Program GAIN Clinical Collaborators

30 to 6010 to 292 to 91

One or more state or county wide systems uses the GAIN

One or more state or county wide systems considering using the GAIN

07/05

44

Progressive Assessment Approach GAIN Short Screener (2 pages, 5 min) for use in a general

population or as fast/simple measure severity– of substance use disorders is needed.

Screening for Targeted Referral – Assessment of who needs crisis or brief intervention (e.g., by SAP,

doctor) vs. more detailed assessment and specialized treatment/referral – Decision rules about where to send may be more complex (e.g.,

substance abuse, mental health, both) Comprehensive Biopsychosocial

– Used to identify common problems and how they are interrelated– Requires more skill in administration and even more in interpretation

Specialized Assessment– The bio-psycho-social may identify areas where additional assessment

by a specialist (e.g., psychiatrist, school counselor) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan

Program Level Assessment– For program management, evaluation, and planning

45

Common Hierarchical Structure of the GAIN’s Psychopathology Scales

Substance Issues Index (SII)Substance Abuse Scale (SAS)Substance Dependence Scale (SDS)

Substance Problem Scale (SPS)

Somatic Symptom Index (SSI)Depression Symptom Scale (DSS)Homicidal/Suicidal Thought Index (HSTI)Anxiety/Fear Symptom Scale (AFSS)Traumatic Distress Scale (TDS)

Internal Mental Distress Scale (IMDS)

Inattentiveness Disorder Scale (IDS)Hyperactivity-Impulsivity Scale (HIS)Conduct Disorder Scale (CDS)

Behavior Complexity Scale (BCS)

General Conflict Tactic Scale (GCTS)Property Crime Scale (PCS)Interpersonal Crime Scale (ICS)Drug Crime Scale (DCS)

Crime/Violence Scale (CVS)

General Individual Severity Scale (GISS)

Confirmatory factor analysis demonstrates that this is reliable overall and stable across adults and adolescents, outpatient & residential (confirmatory fit index =.97; Root Mean Square Error=.04)

46

GAIN Short Screen (GAIN-SS) Administration Time: 4-5 minute Training Requirements: Minimal Mode: Self or staff administered Purpose: Designed for use in general populations or where there is less control

to identify who has a disorder warranting further assessment or behavioral intervention, measuring change in the same, and comparing programs

Scales: The total scale (20-symptoms) and its 4 subscales (5-symptoms each) for internal disorders (somatic, depression, suicide, anxiety, trauma, behavioral disorders (ADHD, CD), substance use disorders (abuse, dependence), and crime/violence (interpersonal violence, property crime, drug related crime) can be used to generate symptom counts for the past month to measure change, past year to identify current disorders and lifetime to serve as covariates/validity checks.

Reports: There are currently no reports.

47

GAIN Short Screen (GAIN-SS)

Total Disorder Screener (TDScr)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Prevalence (% 1+ disorder)

Sensitivity (% w disorder above)

Specificity (% w/o disorder below)

(n=6194 adolescents)

Low Mod. High

99% prevalence, 91% sensitivity, & 89%

specificity at 3 or more symptoms

Using a higher cut point increases prevalence and specificity, but

decreases sensitivity

Total score has alpha of .85 and is

correlated .94 with full GAIN version

Source: Dennis et al 2005 GSS manual

48

GSS Performance by Subscale and Disorders

Prevalence Sensitivity Specificity Screener/Disorder 1+ 3+ 1+ 3+ 1+ 3+ Internal Disorder Screener (0-5) Any Internal Disorder 81% 99% 94% 55% 71% 99% Major Depression 56% 87% 98% 72% 54% 94% Generalized Anxiety 32% 56% 100% 83% 44% 83% Suicide Ideation 24% 43% 100% 84% 41% 79% Mod/High Traumatic Stress 60% 82% 94% 60% 55% 90%

External Disorder Screener (0-5) Any External Disorder 88% 97% 98% 67% 75% 96% AD, HD or Both 65% 82% 99% 78% 51% 85% Conduct Disorder 78% 91% 98% 70% 62% 90%

Substance Use Disorder Screener (0-5) Any Substance Disorder 96% 100% 96% 68% 73% 100% Dependence 65% 87% 100% 91% 30% 82% Abuse 30% 13% 89% 25% 14% 28%

Crime Violence Screener (0-5) Any Crime/Violence 88% 99% 94% 49% 76% 99% High Physical Conflict 31% 46% 100% 70% 38% 77% Mod/High General Crime 85% 100% 94% 51% 71% 100%

Total Disorder Screener (0-5)Any Disorder 97% 99% 99% 91% 47% 89% Any Internal Disorder 58% 63% 100% 98% 8% 28% Any External Disorder 68% 75% 100% 99% 10% 37% Any Substance Disorder 89% 92% 99% 92% 20% 51% Any Crime/Violence 68% 73% 100% 96% 10% 32%

Low (0), Moderate (1-2), and High (3+) cut points can

be used to identify the need

for specific types of

interventions

Moderate can be targeted where resources allow or where a more

assertive approach is

desired

Mod/Hi can be used to evaluate

program delivery/referral

49

GAIN Quick (GAIN-Q) Administration Time: 20-30 minute Training Requirements: ½ day Mode: Generally Staff Administered on Computer (can be done on paper

or self administered) Purpose: Designed for use in targeted populations to support brief

intervention or referral for further assessment or behavioral intervention Scales: The GQ has total scale (99-symptoms) and 15 subscales

(including more detailed versions of the GSS scales and subscales plus scales for service utilization, sources of psychosocial stress, and health problems). All scales focus on the past year only and it is primarily used to support motivational interviewing or for a one time assessment (though there is a shorter follow-up version).

Reports: Summary narrative report and a graphic individual profile to support clinical decision making.

50

The GAIN-Quick can Predict Level of Care

Source: Titus et al, 2003; ATM data

-0.6

-0.4

-0.2

0.0

0.2

0.4

0.6

Depre

ssio

n S

ym

pto

m Index

Suic

ide R

isk

Index

Anxie

ty S

ym

pto

m Index

Inte

rnal B

ehavio

r In

dex

Att

enti

on-H

ypera

ctiv

ity

Dis

ord

er

Index

Conduct

Dis

ord

er-

Aggre

ssio

n Index

Genera

l C

rim

e Index

Exte

rnal B

ehavio

r In

dex

Subst

ance

Use

and A

buse

Subst

ance

Dependence

Index

Subst

ance

Pro

ble

m Index

TC (n=288) STR (n=604) OP/IOP (n=513)

Good reliability (alpha over .9 on main scales, .7 on subscales) and correlated .9 or higher with full GAIN scale

Z s

core

fro

m m

ean

51

GAIN Initial (GAIN-I) Administration Time: 90 (core) to 120 (full) minute Training Requirements: 3 days + review/feedback on 2 to 6 tapes (or direct observations)

over 1 to 2 months; formal certification program for administration and trainers Mode: Generally Staff Administered on Computer (can be done on paper or self

administered) Purpose: Designed to provide a standardized biopsychosocial for people presenting to a

substance abuse treatment using DSM-IV for diagnosis, ASAM for placement, and needing to meet common (CARF, JCAHO, insurance, CDS/TEDS, Medicaid, CSAT, NIDA) requirements for assessment, diagnosis, placement, treatment planning, accreditation, performance/outcome monitoring, economic analysis, program planning and to support referral/communications with other systems

Scales: The GI has 9 sections (access to care, substance use, physical health, risk and protective behaviors, mental health, recovery environment, legal, vocational, and staff ratings) that include 103 long (alpha over .9) and short (alpha over .7) scales, summative indices, and over 2000 created variables to support clinical decision making and evaluation. It is also modularized to support customization

52

GAIN-I’s Main Reports GAIN Referral and Recommendation Summary (GRRS): A text-based

narrative in MS Word designed to be edited and shared with specialists, clinical staff from other agencies, insurers and lay people.

Individual Clinical Profile (ICP): A more detailed report in MS Access designed to help triage problems and help the clinician go back to the GAIN for more details if necessary (generally not edited or shared).

Personal Feedback Reports (PFR): A text based summary to support the motivational interviewing or MET based on the GAIN-I (or GAIN-Q).

Validity Reports: A list of potential problems and areas for clarification and.

Other: Custom reports to word, excel or transferring data from/to other data systems.

53

Other Measures

Collateral versions of all three measures Follow-up versions of all three measures Spanish Translation of all three measures Native American Module CSAT, State, Organization, Program, and

Project Specific (aka CORE) versions Ability to customize by site within prescribed

parametersOver 4 dozen scientist using the data to develop additional

clinical guidance on diagnosis, placement, treatment planning, treatment effectiveness and economic analysis

More information is available at www.chestnut.org/li/gain

http://www.chestnut.org/li/gain

54

CSAT Adolescent Treatment Cooperative Data Set

Recruitment: 1998-2004

Sample: The 2004 CSAT adolescent treatment data set included data on 5,468 adolescents from 67 local evaluations (and is growing exponentially in people, sites, and number of follow-ups)

Levels of Care: Adolescent EI, OP, IOP, STR, LTR, CC

Instrument: Global Appraisal of Individual Needs (GAIN)

Follow-up: Over 85% follow-up 3, 6, & 9 months post discharge

Funding: CSAT contract 270-2003-00006 and multiple individual grants

55

Demographic Characteristics

74%

6%

1%

17%

45%

15%

16%

17%

76%

7%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male

Am. Native

Asian

African Am.

White

Hispanic

Mixed/Other

Under 14

15-17

18 to 25

Source: CSAT AT Common GAIN Data set

300 or more adolescents in each subgroup

56

Other Characteristics

50%

39%

34%

86%

45%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Single Parent

Homeless orRunaway

Employed

In School

Recently in a Controlled

Environment

75%Juvenile Justice

Involvement


57

Weekly/Daily Substance Use Pattern

65%

20%

52%

5%

3%

8%

30%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD Use

Alcohol

Marijuana

Cocaine/Crack

Heroin/Opioids

Other Drugs

14 or more days in Controlled Environment

In our data and in TEDS, 1 in 5 did not use in the month

before intake – hence the use of 90 day window and

measures of pre-CE use


58

Severity of Substance Use Disorders

88%

86%

65%

58%

43%

34%

12%

11%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Self reported abuse/dependence

First use under 15

Weekly or more AOD use

Past Year Dependence

Prior Substance Abuse Tx

Past week withdrawal

Past weeksevere withdrawal

First use under 10


59

Mixed Problem Recognition

35%

81%

92%

99%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Acknowledges AOD problem

Believes treatment

needed

Self reports 1+abuse/dependence

Problem criteria

Gives one or morereasons to quit


60

High Risk Recovery Environments

29%

52%

61%

17%

67%

79%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Reg

ular

alc

ohol

use In home

among work/school peers

among social peers

Reg

ular

dru

g us

e In home

among work/school peers

among social peers


61

High Rates of Other Psychiatric Problems

49%

38%

21%

28%

32%

28%

67%

59%

48%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Internal Disorder

Depressive Disorder

Anxiety Disorder

Trauma Related Disorder

Any Self Mutilation

Any homicidal/suicidal thoughts

Any External Disorder

Conduct Disorder

Attention Deficit-Hyperactivity Disorder

(ADHD)

With External Disorders more

prominent in AdolescentsSource: CSAT AT Common GAIN Data set

62

Psychiatric Problems Increase 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

Like Dependence, “Short Term” actually the most severe

on psychiatric disorders

63

High rate of crime and violence


86%

72%

58%

57%

51%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any violence orillegal activity

Physical Violence

Property Crimes

Drug Related Crime

Interpersonal/violentCrimes

Past Year

64

Intensity of Juvenile Justice System Involvement

Source: CSAT 2004 AT Common GAIN Data set (n= 5,468 adolescents from 67 local evaluations)

17% In detention/jail 14+ days

25% On probation or parole 14+ days w/ 1+ drug screens

17% Other probation/parole/detention

16% Other JJ status

8% Past arrest/ JJ status

17% Past year illegal activity/SA use

Highest severity for Long Term

Residential (followed by

STR, IOP, OP)

65

High Rates of HIV/STI risk behaviors

81%

57%

16%

61%

51%

35%

29%

23%

4%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sexual Activity

Victimization

Needle Use

Sexual Activity

Sex Under AOD Influence

Multiple Sex Partners

UnprotectedSex

Victimization

Needle Use

Lif

etim

eP

ast

90 D

ays


66

Multiple Problems* are the Norm


NoneOne

Two

Three

Four

Five to Twelve

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Most acknowledge 1+ problems

Few present with just one problem

(the focus of traditional research)

In fact, over half present

acknowledging 5+ major problems

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

67

No. of Problems* by Severity of Victimization

Source: CSAT AT Common GAIN Data set (odds for High over odds for Low)

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD,

CD, victimization, violence/ illegal activity)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low (31%) Moderate (17%) High (51%)

Five or More

Four

Three

Two

One

None

Those with high lifetime levels of

victimization have 117 times higher

odds of having 5+ major problems*

GAIN General Victimization Scale Score (Row %)

68

Other Assessment and Treatment Resources

Assessment Instruments – GAIN Coordinating Center at www.chestnut.org/li/gain – CSAT TIP 3 at

http://www.athealth.com/practitioner/ceduc/health_tip31k.html – NIAAA Assessment Handbook at

http://www.niaaa.nih.gov/publications/instable.htm

Treatment Programs– CSAT CYT, ATM, ACC and other treatment manuals at

www.chestnut.org/li/apss/csat/protocols and on CDs provided– SAMHSA Knowledge Application Program (KAP) at

http://kap.samhsa.gov/products/manuals – NCADI at www.health.org – National Registry of Effective Prevention Programs

Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov

http://www.chestnut.org/li/gain

http://www.athealth.com/practitioner/ceduc/health_tip31k.html

http://www.niaaa.nih.gov/publications/instable.htm

http://www.chestnut.org/li/apss/csat/protocols

http://kap.samhsa.gov/products/manuals

http://www.health.org/

http://www.modelprograms.samhsa.gov/

69

Other Resources (continued) Implementing Evidenced based practice

– Central East ATTC Evidence Based Practice Resource Page http://www.ceattc.org/nidacsat_bpr.asp?id=LGBT

– Northwest Frontier ATTC Best Practices in Addiction Treatment: A Workshop Facilitator's Guide http://www.nattc.org/resPubs/bpat/index.html

– Turning Knowledge into Practice: A Manual for Behavioral Health Administrators and Practitioners About Understanding and Implementing Evidence-Based Practices http://www.tacinc.org/index/viewPage.cfm?pageId=114

– Evidence-Based Practices: An Implementation Guide for Community-Based Substance Abuse Treatment Agencies http://www.uiowa.edu/~iowapic/files/EBP%20Guide%20-%20Revised%205-03.pdf

– National Center for Mental Health and Juvenile Justice Evidence Based Practice resource list at http://www.ncmhjj.com/EBP/default.asp

Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) www.chestnut.org/li/apss/sasate

2006 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/jmate/

– next meeting March 27-29, 2006, Baltimore, MD

http://www.ceattc.org/nidacsat_bpr.asp?id=LGBT

http://www.nattc.org/resPubs/bpat/index.html

http://www.tacinc.org/index/viewPage.cfm?pageId=114

http://www.uiowa.edu/~iowapic/files/EBP%20Guide%20-%20Revised%205-03.pdf

http://www.uiowa.edu/~iowapic/files/EBP%20Guide%20-%20Revised%205-03.pdf

http://www.ncmhjj.com/EBP/default.asp

http://www.chestnut.org/li/apss/sasate

http://www.mayatech.com/cti/jmate/

70

What are the pitfalls of EBP?

EBP generally causes some staff turnover EBP often shines a light on staff or work place problems

that would otherwise be ignored EBP often impact a wide range of existing procedures and

policies – requiring modification and provoking resistance EBP (and most organizational changes) will fail without

good senior staff leadership EBP typically require going for more funds from grant or

other funders On-going needs assessment will create demand for more

change and more EBP

71

Summary of Evidenced Based Practice Section

Achieving reliable outcomes requires reliable measurement, protocol delivery and on-going performance monitoring.

The GAIN is one measure that is being widely used by CSAT grantees and others trying to address gaps in current knowledge and move the field towards evidenced based practice.

Standardized and more specific assessment helps to draw out treatment planning implications of readiness for change, recovery environment, relapse potential, psychopathology, crime/violence, and HIV risks.

Adolescents entering more intensive levels of care typically have higher severity.

Multiple problems and child maltreatment are the norm and are closely related to each other.

There is a growing number of standardized assessment tools, treatment protocols and other resources available to support evidenced based practices

72

Part 4 Treatment Effectiveness: Findings from four recent treatment outcome studies

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

74

Context Circa 1997 Cannabis had become more potent, was associated with a wide of

problems (particularly when combined with alcohol), and had become the leading substances mentioned in arrests, emergency room admissions, autopsies, and treatment admissions (doubling in in 5 years)

Over 80% of adolescents with Cannabis problems were being seen in outpatient setting

The median length of stay was 6 weeks, with only 25% making it 3 months

There were no published manuals targeting adolescent marijuana users in outpatient treatment

The purpose of CYT was to manualize five promising protocols, field test their relative effectiveness, cost, and benefit-cost and provide them to the field

Source: Dennis et al, 2002

75

Randomly Assigns to:

MET/CBT5Motivational Enhancement Therapy/

Cognitive Behavioral Therapy (5 weeks)



FSN

Family Support Network

Plus MET/CBT12 (12 weeks)

Trial 2Trial 1Incremental Arm Alternative Arm

Two Effectiveness Experiments

ACRAAdolescent Community

Reinforcement Approach(12 weeks)

MDFTMultidimensional Family Therapy

Randomly Assigns to:



(12 weeks)


76

Contrast of the Treatment Structures

Individual Adolescent Sessions

CBT Group Sessions

Individual Parent Sessions

Family Sessions/Home Visits

Parent Education Sessions

Total Formal Sessions

Type of ServiceMET/CBT5

MET/CBT12 FSN ACRA MDFT

2

3

5

2

10

12

2

10

4

6

22

10

2

2

14

6

3

6

15

Case management/Other Contacts

As needed

As needed

As needed

Total Expected Contacts 5 12 22+ 14+ 15+

Total Expected Hours 5 12 22+ 14+ 15+

Total Expected Weeks 6-7 12-13 12-13 12-13 12-13

Source: Diamond et al, 2002

77

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


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

78

$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

79

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

12-months (88% all five interviews) Collateral interviews were obtained at intake, 3- and 6-months

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

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

Long term follow-up completed on 90% at 30-months Self reported marijuana use largely in agreement with urine test

at 30 months (13.8% false negative, kappa=.63) Good reliability (alphas over .85 on main scales) and

correlations with collateral reports (r=.4 to .7)

Source: Dennis et al, 2002, 2004

80

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

Source: Tims et al, 2002

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

81

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

82

Institutional Involvement

25%

87%

47%

62%

0%

20%

40%

60%

80%

100%

In school Employed Current JJInvolvement

Coming fromControlled

Environment


83

Patterns of Substance Use

9%17%

71%73%

0%

20%

40%

60%

80%

100%

Weekly Tobacco Use

WeeklyCannabis Use

Weekly AlcoholUse

Significant Timein ControlledEnvironment


84

Multiple Problems were 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


85

Substance Use Severity was Related to Other Problems

* p<.05

Source: Tims et al 2002

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)

86

CYT Increased Days Abstinent and Percent in Recovery*


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

87

Similarity of Clinical Outcomes by Conditions


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)

88

Moderate to large differences in Cost-Effectiveness by Condition


$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

89

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

90

Change in Quarterly Costs to Society(12 months minus Intake)


$(25,000)

$(20,000)

$(15,000)

$(10,000)

$(5,000)

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

MET/CBT5

MET/CBT12

FSN MET/CBT5

ACRA MDFT Average

$(25,000)

$(20,000)

$(15,000)

$(10,000)

$(5,000)

$-

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000Significant Reduction in Cost to Society Overall

Three sites went down significantly, one went up significantly

No Significant Difference by Condition

Cond x Site: 4 sig reduction, 2 sig Incr, 6 no sig dif (low power)

91

Cumulative Recovery Pattern at 30 months

Source: Dennis et al, forthcoming

37% Sustained Problems

5% Sustained Recovery

19% Intermittent, currently in

recovery

39% Intermittent, currently not in

recovery

The Majority of Adolescents Cycle in and out of Recovery

Source: Dennis et al forthcoming

92

Environmental Factors are also the Major Predictors of Relapse

RecoveryEnvironment

Risk

SocialRisk

FamilyConflict

FamilyCohesion

SocialSupport

SubstanceUse

Substance-RelatedProblems

Baseline

Baseline

Baseline Baseline

.32.18

-.13

.21

-.08

.32

.19

.22

.32

.22

.17

.11

.43

.77

.82

.74 .58

-.54

-.09

.19

Source: Godley et al (2005)

Model Fit CFI=.97 to .99 RMSEA=.04 to .06

AOD use in the home, family problems, homelessness, fighting,

victimization, self help group participation, structure activities

Peer AOD use, fighting, illegal activity,

treatment, recovery, vocational activity

The effects of adolescent treatment are mediated by the extent to which they lead to actual changes in the recovery environment or peer group

93

Crime/Violence and Substance Problems Interact to Predict Recidivism

Low

Mod.

High

LowMod

.High0%

20%

40%

60%

80%

100%

Source: CYT & ATM Data

12 m

onth

rec

idiv

ism

Crime/ Violence predicted recidivism

Substance Problem Severity predicted

recidivismKnowing both was the

best predictor

Substance Problem

Scale

Crime and Violence

Scale

94

Crime/Violence and Substance Problems Interact to Predict Violent Crime or Arrest

Low

Mod.

High

LowMod

.High

Source: CYT & ATM Data

12 m

onth

rec

idiv

ism

T

o vi

olen

t cri

me

or a

rres

t

Substance Problem

Scale

Crime and Violence

Scale

0%

20%

40%

60%

80%

100%

Crime/ Violence predicted

violent recidivism

(Intake) Substance Problem Severity did

not predict violent recidivism

Knowing both was the best predictor

95

Post Script on CYT

The CYT interventions provide replicable models of 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 – including many who continued to vacillate in and out of recovery after discharge from CYT.

Descriptive, outcome and economic analyses have been published All five interventions are currently being used in subsequent

experiments The MET/CBT5 intervention is currently being replicated in a 38 site

study and ACRA will be replicated in a multisite study slated to be funded next year.

Over 40,000 copies of the CYT manuals have been distributed by NCADI and as many electronic copies have been distributed by CD or the website

97

Context Circa 1998-99

Few research studies of existing treatment programs and no published manuals to support replication for the few studies that were done

Not clear whether research based treatment protocols were any better than what the better programs were already doing

The purpose of ATM was to manualize existing programs that appeared promising, then to evaluate them using the same measures and methods as CYT (allowing quasi-experimental comparisons)

98

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.

99

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

100

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

101

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

Per

cent

Sti

ll in

Tre

atm

ent

Long Term Residential (median=154 days; n=222)

Short Term Residential (median=31 days; n=589)

Outpatient (median= 88 days; n=554)

About half of those in OP stay 90 or more days

Over half the STR say more than 30 days

102

Adolescents more likely to transfer

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

103

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

104

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

105

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

106

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

Residential programs start more severe, go down sharply,

but then come back over time

Note the sharp “hinge” in outcomes

during the active phase of AOD

treatment

Short- Term Resid. \t,s,ts

Long- Term Resid\t,ts

Outpatient\t,s

107

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

LTR more like OP on symptoms

count



Outpatient\t,s

108

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



Outpatient\t,s

Longer term outcomes are

similar on substance use

109

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

110

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



Outpatient\t,s

Note the lack of a hinge; Effect is generally indirect (via

reduced use) not specific

111

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

112

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

113

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



Outpatient\t,s

Residential Treatments have a specific effect

Outpatient Treatments has an indirect effect

114

High Rates of Victimization were 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

115

Victimization and Level of Care Interact to Predict 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 -High OP - Low/Mod Resid-High Resid - Low/Mod.

CHS Outpatient CHS Residential Traumatized groups have higher severity

High trauma group does not respond to OP

Both groups respond to residential treatment

116

How do CHS OP’s high GVS outcomes compare with other OP programs on average?

Source: CYT and ATM Outpatient Data Set Dennis 2005

-1.00

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Z-S

core

on

Sub

stan

ce F

requ

ency

Sca

le (

SF

S) CYT Total (n=217; d=0.51)

ATM Total (n=284; d=0.41)

CHSOP (n=57; d=0.18)

Other programs serve clients who have significantly

higher severity

And on average they have moderate effect sizes even

with high GVS

Green line is CHS OP’s High GVS adolescents; they have some initial gains but substantial relapse

117

Which 5 OP programs did the best with high GVS adolescents?


-1.00

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00


Z-S

core

on

Sub

stan

ce F

requ

ency

Sca

le (

SF

S) 7 Challenges (n=42; d=1.21)

Tucson Drug Court (n=27; d=0.65)

MET/CBT5a (n=34; d=0.62)

MET/CBT5b (n=40; d=0.55)

FSN/MET/CBT12 (n=34; d=0.53)

CHSOP (n=57; d=0.18)

The two best were used with much higher severity adolescents and

TDC was not manualized

Next we can check to see if they are any more similar in severity

118

-1.00

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00


Z-S

core

on

Sub

stan

ce F

requ

ency

Sca

le (

SF

S)

MET/CBT5a (n=34; d=0.62)

MET/CBT5b (n=40; d=0.55)

FSN/MET/CBT12 (n=34; d=0.53)Epoch (n=72; d=0.33)

TSAT (n=66; d=0.35)CHSOP (n=57; d=0.18)

Which 5 OP Programs, of similar severity, did the best with high GVS adolescents?


Trying MET/CBT5 because it is

stronger, cheaper, and easier to

implement

Not much improvement and they do not work quite as well

Currently CHS is doing an experiment comparing its regular OP with MET/CBT5

119

Post script on ATM

The ATM interventions represent a relatively unprecedented sharing of technology between programs and the rest of the field.

By choosing to use the GAIN instrumentation to facilitate comparisons to each other and CYT, the ATM investigators started a movement…over half of the current generation of studies are being pooled to make a common data set of over 7000 adolescents entering treatment (with follow-up data 3 to 12 months latter) that is being used to support research on evidenced based practice.

Site and multisite level findings from ATM have been published and more work is under way – including methodological work on to integrate experimental, quasi-experimental and non-experimental findings in a meta analytic synthesis

All of the manuals are published and distributed via website and the CDs provided

Findings from the Assertive Continuing Care (ACC)

Experiment

183 adolescents admitted to residential substance abuse treatment

Treated for 30-90 days inpatient, then discharged to outpatient treatment

Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC)

Over 90% follow-up 3, 6, & 9 months post discharge

Source: Godley et al 2002, forth coming

121

Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17)

Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60 70 80 90

Days after Residential (capped at 90)

Per

cen

t of

Clie

nts

Cont.CareAdmis.

Relapse

122

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)

123

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.

124

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

125

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

126

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

127

Post script on ACC

The ACC intervention improved adolescent adherence to the continuing care expectations of both residential and outpatient staff; doing so improved the rates of short term abstinence and, consequently, long term abstinence.

Despite these GAINs, many adolescents in ACC (and more in UCC) did not adhere to continuing care plans.

The ACC preliminary findings are published and the main findings are currently under review.

Several CSAT grantees are also seeking to replicate ACC as part of the Adolescent Residential Treatment (ART) program

A second ACC experiment is currently under way to evaluate whether providing contingency management will further improve outcomes

The ACC manual is being distributed via the website and the CD you have been provided.

128

Meta Analysis of the Effectiveness of Programs for Juvenile Offenders

N of

Offender Sample Studies

Preadjudication (prevention) 178

Probation 216

Institutionalized 90

Aftercare 25

Total 509

Source: Adapted from Lipsey, 1997, 2005

129

Most Programs are actually a mix of components

Average of 5.6 components distinguishable in program descriptions from research reports

Intensive supervisionPrison visitRestitutionCommunity serviceWilderness/Boot campTutoringIndividual counselingGroup counselingFamily counselingParent counselingRecreation/sportsInterpersonal skills

Anger managementMentoringCognitive behavioralBehavior modificationEmployment trainingVocational counselingLife skillsProvider trainingCaseworkDrug/alcohol therapyMultimodal/individualMediation


130

Most programs have small effectsbut those effects are not negligible

The median effect size (.09) represents a reduction of the recidivism rate from .50 to .46

Above that median, most of the programs reduce recidivism by 10% or more

One-fourth of the studies show recidivism reductions of 30% or more, that is, a recidivism rate of .35 or less for the treatment group compared to .50 for the control group

The “nothing works” claim that rehabilitative programs for juvenile offenders are ineffective is false


131

Major Predictors of Bigger Effects

1. Chose a strong intervention protocol based on prior evidence

2. Used quality assurance to ensure protocol adherence and project implementation

3. Used proactive case supervision of individual

4. Used triage to focus on the highest severity subgroup

132

Impact of the numbers of Favorable features on Recidivism (509 JJ studies)


Usual Practice has little

or no effect

133

Some Programs Have Negative or No Effects on recidivism

“Scared Straight” and similar shock incarceration program

Boot camps mixed – had bad to no effect

Routine practice – had no or little (d=.07 or 6% reduction in recidivism)

Similar effects for minority and white (not enough data to comment on males vs. females)

The common belief that treating anti-social juveniles in groups would lead to more “iatrogenic” effects appears to be false on average (i.e., relapse, violence, recidivism for groups is no worse then individual or family therapy)


134

Program types with average or better effects on recidivism

AVERAGE OR BETTER BETTER/BEST

Preadjudication

Drug/alcohol therapy Interpersonal skills training

Parent training Employment/job training

Tutoring Group counseling

Probation

Drug/alcohol therapy Cognitive-behavioral therapy

Family counseling Interpersonal skills training

Mentoring Parent training

Tutoring

Institutionalized

Family counseling Behavior management

Cognitive-behavioral therapy Group counseling

Employment/job training Individual counseling

Interpersonal skills trainingSource: Adapted from Lipsey, 1997, 2005

135

Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Practice in Reducing Recidivism (29% vs. 40%)

Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving Multisystemic Therapy Functional Family Therapy Multidimensional Family Therapy Adolescent Community Reinforcement Approach MET/CBT combinations and Other manualized CBT

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

136

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

137

Some Concluding Thoughts

138

A Fearless Appraisal… We are entering a renaissance of new knowledge in this area, but are only

reaching 1 of 10 in need Several interventions work, but 2/3 of the adolescents are still having

problems 12 months later Effectiveness is related to severity, intervention strength,

implementation/adherence, and how assertive we are in providing treatment

As other therapies have caught up technologically, 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

139

Recommendations for Further Developments…

We need to target the latter phases of treatment to impact the post-treatment recovery environment and/or social risk groups that are the main predictors of long term relapse

We need to move beyond focusing on acute episodes of care to focus on continuing care and a recovery management paradigm

We need to better understand the impact of involvement in juvenile justice system and how it can be harnessed to help

More work is need on the use of schools as a location for providing primary treatment (they have entrée to the population and appear to be the venue of choice) and recovery-schools to provide support for those coming out of residential treatment

140

Common Strategies you can do NOW Standardize assessment and identify most common problems Pool knowledge about what staff have done in the past, whether it

worked, and what the barriers were Identify system barriers (e.g., criteria to local access case management,

mental health) that could be avoided if thought of in advance Identify existing materials that could help and make sure they are

readily available on site Identify promising strategies for working with the adolescent, parents,

or other providers Develop a 1-2 page checklist of things to do when this problem comes up Identify a more detailed protocol and trainer to address the problem,

then go for a grant to support implementation

141

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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.

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