the current renaissance of adolescent treatment michael dennis, ph.d. chestnut health systems,...

The Current Renaissance of Adolescent Treatment

Michael Dennis, Ph.D.Chestnut Health Systems, Bloomington, IL

Presentation for National Conference onBoys & Girls at Risk:The Emerging Science of Gender Differences , Madison, WI July 21-22, 2008. This presentation reports on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contracts 270-2003-00006 and 270-07-0191, as well as several individual CSAT, NIAAA, NIDA and private foundation grants. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: [email protected]

2

1. Examine the prevalence, course, and consequences of adolescent substance use, co-occurring disorders and the unmet need for treatment overall and by gender

2. Summarize major trends in the adolescent treatment system and Wisconsin

3. Highlight what it takes to move the field towards evidenced-based practice related to assessment, treatment, program evaluation and planning

4. Present the findings from several recent treatment outcome studies on substance abuse treatment research, trauma and violence/crime

Goals of this Presentation are to

3

Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246)

Dependence 5%

Abuse 4%

Regular AOD Use 8%

Any Infrequent Drug Use 4%

Light Alcohol Use Only 47%

No Alcohol or Drug Use

32%

Source: 2002 NSDUH

4

Problems Vary by Age

Source: 2002 NSDUH and Dennis et al forthcoming

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

No Alcohol or Drug Use

Light Alcohol Use Only

Any Infrequent Drug Use

Regular AOD Use

Abuse

Dependence

NSDUH Age Groups

Severity CategoryAdolescent

OnsetRemission

Increasing rate of non-

users

5

Higher Severity is Associated with Higher Annual Cost to Society Per Person

Source: 2002 NSDUH

$0$231 $231

$725$406

$0$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

No Alcohol orDrug Use

Light Alcohol

Use Only

AnyInfrequentDrug Use

Regular AODUse

Abuse Dependence

Median (50th percentile)

$948

$1,613

$1,078$1,309

$1,528

$3,058Mean (95% CI)

This includes people who are in recovery, elderly, or do not use

because of health problems Higher Costs

6

Past Year Alcohol or Drug Abuse or Dependence

Source: OAS, 2006

10.8% Wisc vs.9.3% National

7

Past Year Alcohol Abuse or Dependence

Source: OAS, 2006

10.6% Wisc vs.7.7% National

8

Pattern of Teen Substance Use in WI by Gender\a

18%

3%

23%

24%

15%

14%

10%

9%

19%

21%

30%

27%

45%

42%

19%

20%

19%

20%

2%

20%

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

Female

Male

Female

Male

More than Marijuana

Marijuana use

Alcohol Intoxication

Alcohol or Tobacco Use

No Use

\a Each severity level includes any substance to the right \b More than marijuana is only Cocaine for Past month

Lif

etim

e .

Pas

t M

onth

\b

Source: Wisconsin 2005 YRBSMost drug users also drink to intoxication

9

Behavior Problems by Substance Severity in WI\a

More than Marijuana

Marijuana use



No Use

\a Each lifetime severity level includes any substance to the right

Behavior Problems by Lifetime Substance Severity\a

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Times fighting(year)*

Days carryingweapon (month)*

Times driving underthe influence

(month)*

Times fighting atschool (year)*

Days carried a gun(month)*

Days carriedweapon at school

(month)*

Tim

es/D

ays

\a Each severity level includes any substance to the right *p<.05Source: Wisconsin YRBS

Source: Wisconsin 2005 YRBS * p<.05

Behavior problems increase with substance use severity

10

Victimization by Substance Severity in WI\a

More than Marijuana

Marijuana use



No Use

Victimization Problems by Lifetime Substance Severity\a

0.0

0.5

1.0

1.5

2.0

2.5

Times hurt on school property(year)*

Times had property stolen atschool (year)*

Times threatened at school(year)*

Days felt unsafe at school(month)*

Tim

es/D

ays

\a Each severity level includes any substance to the right *p<.05Source: Wisconsin YRBS

Source: Wisconsin 2005 YRBS * p<.05\a Each lifetime severity level includes any substance to the right

Victimization also goes up with substance use severity

11

Mental Health by Substance Severity in WI\a

More than Marijuana

Marijuana use



No Use


Depression-Suicide Problems by Lifetime Substance Severity\a

0%

10%

20%

30%

40%

50%

Felt sad or hopeless(year)*

Considered suicide(year)*

Made suicide plan(year)*

Attempted suicide(year)*

Injured from suicideattempt (year)*

Per

cent

\a Each severity level includes any substance to the right *p<.05Source: Wisconsin YRBS\a Each lifetime severity level includes any substance to the right

As does mental health…

12

Other Problems by Substance Severity in WI\a

More than Marijuana

Marijuana use



No Use


Other Problems by Lifetime Substance Severity\a

0%

10%

20%

30%

40%

50%

Uncomfortable touch, pictureat school (year)*

Harassed at school (year)* Grades mostly Ds/Fs (year)* Usually do not feel safe atschool (year)*

Per

cent

\a Each severity level includes any substance to the right *p<.05Source: Wisconsin YRBS\a Each lifetime severity level includes any substance to the right

..and other problems

13

Count of Problems by Substance Severity in WI\a

More than Marijuana

Marijuana use



No Use

Source: Wisconsin 2005 YRBS * p<.05\a Each severity level includes any substance to the right

13.3

20.4

7.1

9.0

6.7

9.4

3.94.8

2.6 2.6

-

5

10

15

20

25

Lifetime Past Month

Num

ber

of P

robl

ems

\a Each severity level includes any substance to the right *p<.05

The number of different types of problems also

up with severity

The relationship between the number of problems and substance

use severity is even greater if we focus on

past month use

14

Brain Activity on PET Scan Brain Activity on PET Scan After Using CocaineAfter Using Cocaine

1-2 Min 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377.

Rapid rise in brain activity after taking

cocaine

Actually ends up lower than they

started

15

Normal

Cocaine Abuser (10 days)

Cocaine Abuser (100 days)Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP,

Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.

Brain Activity on PET Scan Brain Activity on PET Scan After Using CocaineAfter Using Cocaine

With repeated use, there is a cumulative

effect of reduced brain activity which

requires increasingly more stimulation (i.e.,

tolerance)

Even after 100 days of abstinence

activity is still low

16Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

17

Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.

pain

Adolescent Brain Development Occurs from the

Inside to Out and from Back to Front

18

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

19

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


20

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

21

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


22

Key Implications

Adolescence is the peak period of risk for and actual on-set of substance use disorders

Adolescent substance use can have short and long terms costs to society

There are real and often lasting consequence of adolescent substance use on brain functioning and brain development

Earlier Intervention during adolescence and young adult hood can reduce the duration of addiction careers

23

Trends in Adolescent (Age 12-17) Treatment Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S.Admissions in the U.S.

Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

95,0

17

95,2

71 109,

123

122,

910

129,

859

131,

194

139,

129

137,

596

140,

542

148,

772

160,

750

158,

752

157,

036

142,

646

136,

660

10,000

30,000

50,000

70,000

90,000

110,000

130,000

150,000

170,000

190,000

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Year of Admission

Num

ber

of A

dmis

sion

s A

ge 1

2-17

.

69% increase from95,017 in 1992

to 160,750 in 2002

15% drop off from 160,750 in 2002 to

136,660 in 2006

24

Change in WI Public Treatment Admissions:

Age at Admission from 1995 to 200511

,00

4

13,4

91

15,5

58

14,6

06

16,4

72

17,5

96

17,3

22

16,8

40 20

,35

4

20,1

54

20,5

06 23

,84

5

22,8

18

25,5

59

-

5,000

10,000

15,000

20,000

25,000

30,00019

92

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

-

5,000

10,000

15,000

20,000

25,000

30,00026+18-2512-17Total

Little Change in Adolescent Admissions

Has led to growing admissions in young

and older adults

25

Variation by State in the Percentage of Adolescent Residential Treatment: 1995 to 2005

10/07

1.6 to 5.9%

Indiana

Kansas

MaineMontana

NebraskaNevada

North Dakota

Puerto Rico

Hawaii

New Mexico

South Dakota

Alabama

Arkansas

Iowa

Oklahoma

Rhode Island

South CarolinaDistrict Of ColumbiaTennessee

Utah

Louisiana

W. Virginia

Minnesota

Wisconsin

New Jersey

North Carolina

Alaska

Delaware

Maryland

Pennsylvania

Georgia

KentuckyVirginia

MichiganNew York

Oregon

Colorado

Texas

New Hampshire

Connecticut

Illinois

Missouri

Arizona

Florida

Ohio

Vermont

Idaho

Massachusetts

California

Washington

Wyoming

% ResidentialMississippi

6.0 to 10.5%

10.6 to 18.7%

18.8 to 29.9%30.0 to 52.3%

Wisconsin significantly lower than the 16%

11 year average for U.S.

26

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

27

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

28

Key Problems

Lack of standardized assessment for substance use disorders, mental health disorders, crime/violence, HIV risk and child maltreatment

No or inconsistent use of placement criteria - knowing nothing about the person other than what door they walked through we can correctly predict 75% (kappa=.51) of the adolescent level of care placements (including ASAM systems)

Virtually no link to actual data on the expected outcomes by level of care to inform decision making related to placement

The lack of the full continuum of care to refer people due to availability or finance

29

Summary of Problems in the Treatment System

The public systems is changing size, referral source, and focus

Less than 50% stay 50 days (~7 weeks) Less the 25% stay the 3 months recommended by

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

outpatient care Major problems are not reliably assessed (if at all) Difficult to link assessment data to placement or

treatment planning decisions

30

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

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

at the individual level and implementation at the program level

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

Introducing reliable and valid assessment that can be used – At the individual level to immediately guide clinical judgments

about diagnosis/severity, placement, treatment planning, and the response to treatment

– At the program level to drive program evaluation, needs assessment, performance monitoring and long term program planning

31

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

32

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

Source: Adapted from Lipsey, 1997, 2005

Average Practice

33

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

Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving MET/CBT combinations and Other manualized CBT Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ACRA) Assertive Continuing Care

Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004

NOTE: There is generally little or no differences in mean effect size between these brand names

34

Need for Short Protocols Targeted at Specific Issues:

Detoxification services and medication, particularly related to opioid and methamphetamine use

Tobacco cessation Adolescent psychiatric services related to depression,

anxiety, ADHD, and conduct disorder Trauma, suicide ideation, & parasuicidal behavior Need for child maltreatment interventions (not just

reporting protocols) HIV Intervention to reduce high risk pattern of sexual

behavior Anger Management Problems with family, school, work, and probation Recovery coaches, recovery schools, recovery housing and

other adolescent oriented self help groups / services

35

Recovery* by Level of Care

* Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT Adolescent Treatment Outcome Data Set (n-9,276)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

Per

cent

in P

ast

Mon

th R

ecov

ery* Outpatient (+79%, -1%)

Residential(+143%, +17%)

Post Corr/Res (+220%, +18%)

OP & Resid

Similar

CC better

36

Need for Tracks, Phases and Continuing Care

Almost a third of the adolescents are “returning” to treatment, 23% for the second or more time

We need to understand what did and did not work the last time and have alternative approaches

We need tracks or phases that recognize that they may need something different or be frustrated by repeating the same material again and again

We need to have better step down and continuing care protocols

37

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

38

On-site proactive urine testing can be used to reduce false negatives by more than half

Reduction in false negative reports at no

additional cost Effects grow when

protocol is repeated

39

Implications of Implementation Science

Can identify complex and simple protocols that improve outcomes

Interventions have to be reliably delivered in order to achieve reliable outcomes

Simple targeted protocols can make a big difference

Need for reliable assessment of need, implementation, and outcomes

40

GAIN Clinical CollaboratorsAdolescent and Adult Treatment Program

10/07

GAIN State System

Virgin Islands

01 to 1011 to 25

26 to 130

Indiana

Kansas

MaineMontana

NebraskaNevada

North Dakota

Puerto Rico

Hawaii

New Mexico

South Dakota

Alabama

Arkansas

Iowa

Oklahoma

Rhode Island

South CarolinaDistrict Of ColumbiaTennessee

Utah

Louisiana

W. Virginia

Minnesota

Wisconsin

New Jersey

North Carolina

Alaska

Delaware

Maryland

Pennsylvania

Georgia

KentuckyVirginia

MichiganNew York

Oregon

Colorado

Texas

New Hampshire

Connecticut

Illinois

Missouri

Arizona

Florida

Ohio

Vermont

Idaho

Massachusetts

California

Washington

Wyoming

GAIN-SS State or County System

Number of GAIN SitesMississippi

41

CSAT GAIN Data (n=15,254)

*Any Hispanic ethnicity separate from race group.

Sources: CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).

3%

17%

9%

71%

79%

28%

32%

42%

16%

27%

19%

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

Short Term Residential

Long Term Residential

Intensive Outpatient

Outpatient

15 to 17 years old

12 to 14 years old

Hispanic*

Mixed/Other

Caucasian

African American

Female

CSAT data dominated by

Male, Caucasians, age 15 to 17

CSAT data dominated by

Outpatient

CSAT residential more likely to be over 30 days

Admin

42

Substance Use Problems

83%

50%

29%

7%

34%

29%

26%

94%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Past Year Substance Diagnosis

Any Past Year Dependence

Any withdrawal symptoms in the past week

Severe withdrawal (11+ symptoms) in past week

Can Give 1+ Reasons to Quit

Any prior substance abuse treatment

Acknowledges having an AOD problem

Client believes Need ANY Treatment

Source: CSAT 2007 AT Outcome Data Set (n=12,601)

43

Past Year Substance Severity by Level of Care

38%

57%

72% 75%86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

UseAbuseDependence

Note: OP=Outpatient, IOP=Intensive Outpatient; LTR= Long Term Residential (90+ days); MTR= Moderate Term Residential (30-90 days); STR=Short Term Residential (0-30 days)


44

Past Year Substance Severity by Gender

46%54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

UseAbuseDependence


45

Past 90 day HIV Risk Behaviors

Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

64%

33%

29%

25%

20%

2%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sexually active

Sex Under the Influence of AOD

Multiple Sex partners

Any Unprotected Sex

Victimized Physically, Sexually, orEmotionally

Any Needle use

46

Sexual Partners by Level of Care

27%33%

39% 38%52%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

No SexualPartners

OneSexualPartner

MultipleSexualPartners


47

Sexual Partners by Gender

32%23%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

No SexualPartners

OneSexualPartner

MultipleSexualPartners


48

Co-Occurring Psychiatric Problems


66%

50%

42%

35%

24%

14%

63%

45%

31%

22%

9%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Co-occurring Psychiatric

Conduct Disorder

Attention Deficit/Hyperactivity Disorder

Major Depressive Disorder

Traumatic Stress Disorder

General Anxiety Disorder

Ever Physical, Sexual or Emotional Victimization

High severity victimization (GVS>3)

Ever Homeless or Runaway

Any homicidal/suicidal thoughts past year

Any Self Mutilation

49

Co-Occurring Psychiatric Diagnoses by Level of Care

29%42%

54% 52%68%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

None

One

Multiple


50

Severity of Victimization by Level of Care

38%

53%64% 59%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

Low

Moderate

High


51

Co-Occurring Psychiatric Diagnoses by Gender

29%

52%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

None

One

Multiple


52

Severity of Victimization by Gender

41%55%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

Low

Moderate

High


53

Past Year Violence & Crime

*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)


80%

68%

63%

48%

45%

43%

85%

71%

39%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any violence or illegal activity

Physical Violence

Any Illegal Activity

Any Property Crimes

Other Drug Related Crimes*

Any Interpersonal/ Violent Crime

Lifetime Juvenile Justice Involvement

Current Juvenile Justice involvement

1+/90 days In Controlled Environment

54

Type of Crime by Level of Care

36%

53%64%

54%67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

Drug Useonly

OtherCrime

ViolentCrime


55

Type of Crime by Gender

46%35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

Drug Useonly

OtherCrime

ViolentCrime


56

Three

None

Five to Twelve

Four

Two

One

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Multiple Problems* are the Norm


Most acknowledge 1+ problems

Few present with just one problem (the

focus of traditional research)

In fact, 45%present acknowledging 5+

major problems

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

57

Number of Problems by Level of Care

39%50% 55%

67%78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

0 to 1

2 to 4

5 or more


58

Number of Problems by Level of Care

41%55%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male Female

0 to 1

2 to 4

5 or more


59

15%

45%

70%

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

100%

Low (OR 1.0)

Mod.(OR=4.8)

High(OR=13.8)

NoneOneTwoThreeFourFive+

No. of Problems* by Severity of Victimization


Those with high lifetime

levels of victimization

have 117 times higher odds of

having 5+ major

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

Severity of Victimization

60

CSAT Adolescent Treatment GAIN Data from 203 level of care x site combinations

Outpatient

General Group Home

Short-Term Residential

Outpatient Continuing CareIntensive Outpatient

Long-term ResidentialModerate-Term Residential

Early InterventionOtherCorrections

Levels of Care

Source: Dennis, Funk & Hanes-Stevens, 2008

61

Ratings of Problem Severity (x-axis) by Treatment Utilization (y-axis) by Population Size (circle size)

12%

20%

14%

8%

14%

12%

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

-0.20 0.00 0.20 0.40 0.60 0.80 1.00

Average Current Problem Severity

Ave

rage

Cur

rent

Tre

atm

ent U

tili

zati

on

.

A Low-Low

B Low- Mod

C Mod-Mod

DHi-Low

EHi-Mod

F. Hi-Hi (CC)

G. Hi-Mod(Env Sx/ PH Tx)

9%

H. Hi-Hi(Intx Sx; PH/MH Tx) 12%

62

Variance Explained in 10 NOMS Outcomes

\1 Past month \2 Past 90 days *All statistically Significant

26%

24%

11%

25%

15%

33%

26%

18%

14%

8%

24%

0% 5% 10% 15% 20% 25% 30% 35%

No AOD Use \1

No AOD related Prob.\1

No Health Problems \2

No Mental Health Prob.\2

No Illegal Activity \2

No JJ System Involve. \1

Living in Community \1

No Family Prob. \2

Vocationally Engaged \1

Social Support \2

Count of above

Percent of Variance Explained

63

Best Level of Care*: Cluster A Low - Low (n=1,025)Best Level of Care*:

Cluster A Low - Low (n=1,025)

99.6%

0.4%0%

20%

40%

60%

80%

100%

120%

Outpatient Higher LOC

% B

est P

redi

cted

Out

com

es

* Based on Maximum Predicted Count of Positive Outcomes

64

Best Level of Care*: Cluster C Mod-Mod (n=1209)

30.2%

7.6%

23.6%

38.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Outpatient IOP OPCC Residential

% B

est P

redi

cted

Out

com

es


65

Best Level of Care*: Cluster F Hi-Hi (CC) (n=968)

81.5%

8.6%

0.0%

9.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Outpatient IOP OPCC Residential

% B

est P

redi

cted

Out

com

es


66

Best Level of Care*: Cluster G Hi-Mod (Env/PH) (n=749)Best Level of Care*:

Cluster G Hi-Mod (Env/PH) (n=749)

94.1%

5.9%0.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Outpatient IOP/OPCC Residential


67

NOMS Outcome: Treatment Received by Gender

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

Initiation with 14 days

Evidenced Based Practice

Engagement for at least 6 weeks

Any Continuing Care (91-180 days)

Substance Use-Abstinent/Reduced 50% at3 Months

12 Month Cost Within Bands for InitialType of Treatment

Male FemaleSource: CSAT 2007 AT Outcome Data Set (n=11,294)

68

NOMS Outcome: 50% Reduction or None

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

Substance Use

Substance Problems

Health Problems

Emotional Problems

Behavioral Problems

Illegal Acitvity

Family Problems

Social Risk

Recovery Environment Risk

Trouble at School or Work

Nights in Psychiatric Inpatient Unit

Costs to Society


69

NOMS Outcome at 12 months post-intake

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

Abstinent (Past Month)

Early Remission (Past Month)

No major health problems

No major mental health problems

No Illegal Activity

Free of the Justice System

Living in the Community

No Family/home problems

In School or Work

Social Support


70

Change in Days Abstinent (while in community) by Level of Care and Gender


0

10

20

30

40

50

60

70

80

90

Intake Last Followup

Day

s o

f A

bst

inen

ce

Female - OP (d=0.43)

Males - OP (d=0.33)

Female - Resid (d=0.82)

Males -Res (d=0.74)

71

MALES: Change in Adjusted Days Abstinent by type of Outpatient Approach


0

10

20

30

40

50

60

70

80

90

Intake Last Followup

Day

s of

ab

stin

ence

FSN (d=0.48)

Other (d=0.44)

METCBT5 (d=0.33)

Total (d=0.33)

Other CBT (d=0.32)

Seven Challenges (d=0.27)

METCBT12 (d=0.2)

EMPACT (d=0.18)

CHS OP (d=0.15)

MDFT (d=0.07)

Manualized Practice Tx (d=0.03)

METCBT7 (d=-0.03)

MST (d=0.87)

Motivational Interviewing (d=0.79)

ACRA/ACC (d=0.53)

72

FEMALES: Change in Adjusted Days Abstinent by type of Outpatient Approach


=

0

10

20

30

40

50

60

70

80

90

Intake Last Follow-up

Day

s of

abs

tine

nce

Other (d=0.51)

CHS OP (d=0.48)

METCBT12 (d=0.48)

Seven Challenges (d=0.44)

Total (d=0.42)

FSN (d=0.41)

Other CBT (d=0.41)

METCBT5 (d=0.4)

METCBT7 (d=0.38)

MDFT (d=0.36)

ACRA/ACC (d=0.35)

EMPACT (d=0.02)

Manualized Practice Tx (d=0.94)

Motivational Interviewing (d=0.87)

MST (d=0.86)

73

36 Site Replication on MET/CBT5

AK

AL

ARAZ

CA CO

CT

DC

DE

FL

GA

HI

IA

ID

IL IN

KS KY

LA

MA

MD

ME

MI

MN

MO

MS

MT

NC

ND

NE

NH

NJ

NM

NV

NY

OH

OK

OR

PARI

SC

SD

TN

TX

UTVA

VTWA

WI

WV

WY

CYT: 4 Sites

EAT: 36 Sites

Source: Dennis, Ives, & Muck, 2008

74

Replication and Site Effects

Treatment can vary by implementation within site/clinic

We want to compare the range of implementation in practice with the clinical trials

In order to compare sites, we will at both the central tendency (median) and distribution using a Tukey Box Plot like the one shown here.

Criteria

Median

Middle 50%

“Range”

-2.00

-1.50

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

2.50

3.00

75

Range of Effect Sizes (d) for Change in Days of Abstinence (intake to 12 months) by Site

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

4 CYT Sites (f=0.39)(median within site d=0.29)

36 EAT Sites (f=0.21)(median within site d=0.49)

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

Coh

en’s

d

Source: Dennis, Ives, & Muck, 2008

EAT Programs did Better than CYT on

average

75% above CYT median

6 programs completely above CYT

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, 2007

77

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

78

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)

79

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.

80

ACC Improved Adherence


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

81

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

82

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

83

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 ACC1 main findings are published and findings from two subsequent experiments are currently under review

CSAT is currently replicating ACRA/ACC in 32 sites

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

84

Recommendations for Further Developments…

Evidenced based interventions can come from both research and practice

Evidence based interventions can improve implementation of treatment and treatment outcomes

Practice based evidence can be used to improve outcomes

Evidenced based interventions and their outcomes can be replicated in practice

Continuing care and is a key determinant of long term outcomes

the current renaissance of adolescent treatment michael dennis, ph.d. chestnut health systems,...

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