what works: advances in adolescent substance abuse treatment and research michael dennis, ph.d....

What works: Advances in Adolescent Substance AbuseTreatment and Research

Michael Dennis, Ph.D.

Chestnut Health Systems,

Bloomington, IL

Presentation for the SAMHSA National Policy Academy on Co-Occurring Mental and Substance Abuse Disorders, April 14-16, 2004, Baltimore, MD. The opinions are those of the author sdo not reflect official positions of the consortium or government . Available on line at www.chestnut.org/li/posters.

Examine the prevalence, course, and consequences of adolescent substance use

Summarize major trends in the adolescent treatment system

Review the current knowledge base on treatment effectiveness

Examine how characteristics and outcomes vary by level of care.

Goals of this Presentation

Change in Past Month Substance Use by Age

Source: Dennis (2002) and 1998 NHSDA.

0

10

20

30

40

50

60

70

80

90

10012

13

14

15

16

17

18

19

20

21

22-2

3

24-2

5

26-2

9

30-3

4

35-3

9

50-6

4

65 +

Age

Alcohol Use

Tobacco Use

Binge Alcohol use

Any Illicit Drug Use

Marijuana Use

Consequences of Substance Use

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

Importance of Perceived Risk

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

Mar

ijua

na

Use

Ris

k &

Ava

ilab

ilit

y

The Adolescent Treatment System

Less than 1/10th of adolescents with substance dependence problems receive treatment

Under 50% stay 6 weeks, 75% stay less than the 3 months recommended by NIDA

From 1992 to 1998, admissions to treatment increased 53% (96,787 to 147,899), but then leveled off in 1999 to 2002

From 1992 to 1998, admissions for treatment of primary, secondary or tertiary marijuana use disorders increased 115% (51,081 to 109,875)

Source: Dennis, Dwaud-Noursi, Muck, & McDermeit, 2003; Hser et al., 2001; OAS, 2000

Change in Adolescent Admissions (1992-1998)

Source: Dennis, Dawud-Noursi, Muck & McDermeit, 2003 and 1992-1998 Treatment Episode Data Set (TEDS)

0

20,00040,000

60,000

80,000

100,000120,000

140,000

160,000

Tot

al

(+53

%)

Mar

ijuan

a(+

115%

)

Alc

ohol

(+20

%)

Stim

ulan

ts(+

146%

)

Hal

luci

noge

ns(-

6%)

Coc

aine

(+35

%)

In

hala

nts

(-

41%

)

Opi

ates

(+13

5%)

Oth

er*

(+15

4%)

Ann

ual A

dmis

sion

s .

1992 admissions

1998 admissions

* including tranquilizers, sedatives and o-t-c

Patterns of Substance Use Problems

Alcohol Only9%

All Other Patterns

16%

Marijuana Only23%

Alcohol and

Marijuana52%

Source: Dennis, Dawud-Noursi, Muck & McDermeit, 2003 and 1998 Treatment Episode Data Set (TEDS)

Sources of Adolescent Referrals

Criminal Justice

System 44%

School/ Community Agency 22%

Self/Family 17%

Other Health Care Provider 5%

Other Substance

Abuse Treatment

Agency 5%

Other16%


Level of Care at Admission

Intensive Outpatient

11%

Detox. or Hospital

5%

Short-Term Residential

6%

Long-Term Residential

9% Outpatient 68%


Severity Varies by Level of Care

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

100%

Weekly use atintake

Dependence First usedunder age 15

Prior Treatment

Outpatient (n=24704)Intensive Outpatient (n=4024)Detoxification or Hospital (n=2062)Short Term Residential (n=2046)Long Term Residential (n=3124)


Relatively Small And New Literature

With over 65% of the studies first published in the past 5 years and over 3 dozen more currently in the field, we are entering a “renaissance of

knowledge” in this area.

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

Key Lessons Effectiveness was associated with therapies that:

– were manual-guided and had developmentally appropriate materials– involved more quality assurance and clinical supervision– achieved therapeutic alliance and early positive outcomes– successfully engaged adolescents in aftercare, support groups, positive

peer reference groups, more supportive recovery environments Interventions that are associated with no or minimal change in substance

use or symptoms:– Passive referrals– Educational units alone – Probation services as usual– Unstandardized outpatient services as usual

Interventions associated with deterioration: – treatment of adolescents in “groups including one or more highly

deviant individuals” or that were mismanaged (but NOT all groups)– treatment of adolescents in adult units and/or with adult

models/materials (particularly outpatient)

Limitations of the Literature

Small sample sizes (most under 50) High rates (30-50%) of refusals by eligible people Unstandardized measures, no measures of abuse or

dependence, no measures of comorbidity Unstandardized and minimally-supervised therapies

(making replication very difficult) Minimal information on services received High rates (20-50%) of treatment dropout High rates of attrition from follow-up (25-54%) leading to

potentially large (unknown) bias

NIAAA/NIDA Other Grantees

CSAT/ NEW Adolescent Treatment Program Other Grantees and Collaborators (80+ sites)

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

Other CSAT Grantees

Other Collaborators

RWJF Reclaiming Futures Program

RWJF Other RWJF Grantees

Other Grants/Contracts

Source: www.chestnut.org/li/apss

Key Features

Pooled data over 3,500 and growing at over 1000/year Diverse samples with low (under 15%) refusal and attrition Use a common standardized measure – Global Appraisal of

Individual Needs (GAIN) with explicit measures of abuse, dependence, comorbidity, ASAM criteria and services received

Manualized interventions, including several experiments and replications of the same intervention across states (publicly available at www.chestnut.org/li/apss )

High treatment completion and follow-up rates (generally 80-90%)

Over 3 dozen people doing research on scales, case mix, matching rules, continuing care, and other topics.

Multiple Co-occurring Problems Are the Norm and Increase with Level of Care

Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) studies

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-OccuringDisorder

Outpatient Long Term Residential Short Term Residential

Severity is Related to Other Problems

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)* p<.05

Source: Tims et al 2002

High Rates of Victimization

Source: Dennis (2004)

71

82 84

52

6973

45

5662

2519

37

0

10

20

30

40

50

60

70

80

90

100

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

Lifetime History of Victimization Acute Victimization

Past Year Victimization Past 90 Day Victimization

Victimization is Related to Severity

Source: Titus, Dennis, et al., 2003

0

5

10

15

20

25

30

35

40

Pre Post

OP - No/Low Victimization OP - Acute Victimization

Resid - No/Low Resid- Acute Victimization

Interaction of Victimization and Treatment Setting on Days of Marijuana Use

Source: Funk, et al., 2003

Traumatized groups have higher severity

Both groups respond to residential treatment

High trauma group does not respond to OP

Illegal Activity (not just possession)

Source: Adolescent Treatment Model (ATM) data

7478

82

69 7168

86

65

8580 81 81

939395

0

10

20

30

40

50

60

70

80

90

100

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

Any Illegal Activity Property crimes Interpersonal crimes

Drug related crimes Acts of Physical Violence

Change in Substance Frequency Indexby Level of Care\a

\a Source: Adolescent Treatment Model (ATM) data; Level 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.

40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\t,s,ts

Change in Substance Problem Indexby Level of Care\a


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

40

50

60

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,s,ts

OP\t,s,ts

Percent in Recovery (no past month use or problems while living in the community)


0%

20%

40%

60%

80%

100%

Intake 3 6 9 12

Months from Intake

STR\t,s,ts

LTR\t,ts

OP\t,s

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

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

270180900

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.10.0

Reducing Relapse After Residential Treatment

Source: Godley et al 2002Days to First Marijuana Use (p<.05)

Per

cent

Rem

aini

ng A

bstin

ent

Usual Continuing Care

Assertive Continuing Care

Concluding Comments

We are entering a renaissance of new knowledge in this area, but are only reaching 1 of 10 in need

Several interventions work, but 2/3 of the adolescents are still having problems 12 months later

We need to move beyond focusing on minor variations in therapy (behavioral brand names) and acute episodes of care to focus on continuing care and a recovery management paradigm

It is very difficult to predict exactly who will relapse so it is essential to conduct aftercare monitoring with all adolescents

Resources Copy of these slides and handouts

– http://www.chestnut.org/LI/Posters/

Assessment Instruments – CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html– NIAAA Assessment Handbook,http://www.niaaa.nih.gov/publications/instable.htm

Adolescent Treatment Manuals– NCADI at www.health.org or www.chestnut.org/li/bookstore– CSAT CYT, ATM and other manuals at www.chestnut.org/li/apss/csat/protocols

Adolescent Treatment Programs and Studies – List of programs by state and summary of pre-2002 studies at www.drugstrategies.com – Cannabis Youth Treatment (CYT) : www.chestnut.org/li/cyt – Persistent Effects of Treatment Study of Adolescents (PETSA):

www.samhsa.gov/centers/csat/csat.html (then select PETS from program resources)– Adolescent Program Support Site (APSS): www.chestnut.org/li/apss

Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE)– Website at www.chestnut.org/li/apss/sasate with bibliography – E-mail Darren Fulmore <[email protected]> to be added to list server– Next conference is June 18, 2004, See website or E-mail Joan Unsicker

<[email protected]> for information about about meeting

ReferencesBukstein, O.G., & Kithas, J. (2002) Pharmacologic treatment of substance abuse disorders. In Rosenberg, D., Davanzo, P., Gershon, S.

(Eds.), Pharmacotherapy for Child and Adolescent Psychiatric Disorders, Second Edition, Revised and Expanded. NY, NY: Marcel Dekker, Inc.Dennis, M.L., (2002). Treatment Research on Adolescents Drug and Alcohol Abuse: Despite Progress, Many Challenges Remain.

Connections, May, 1-2,7, and Data from the OAS 1999 National Household Survey on Drug AbuseDennis, M.L. (2004). Traumatic victimization among adolescents in substance abuse treatment: Time to stop ignoring the elephant in our

counseling rooms. Counselor, April, 36-40.Dennis, M.L., & Adams, L. (2001). Bloomington Junior High School (BJHS) 2000 Youth Survey: Main Findings. Bloomington, IL: Chestnut

Health Systems Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003). The need for developing and evaluating adolescent treatment models.

In S.J. Stevens & A.R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary Models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press and 1998 NHSDA.

Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (in press). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment.

Dennis, M. L., Godley, S. and Titus, J. (1999). Co-occurring psychiatric problems among adolescents: Variations by treatment, level of care and gender. TIE Communiqué (pp. 5-8 and 16). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

Dennis, M. L., Perl, H. I., Huebner, R. B., & McLellan, A. T. (2000). Twenty-five strategies for improving the design, implementation and analysis of health services research related to alcohol and other drug abuse treatment. Addiction, 95, S281-S308.

Dennis, M. L. and McGeary, K. A. (1999). Adolescent alcohol and marijuana treatment: Kids need it now. TIE Communiqué (pp. 10-12). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F., Webb, C., Kaminer, Y., Babor, T., Roebeck, M. C., Godley,

M. D., Hamilton, N., Liddle, H., Scott, C., & CYT Steering Committee. (in press). The Cannabis Youth Treatment (CYT) experiment Rationale, study design, and analysis plans. Addiction, 97, 16-34..

Dennis, M.L., & White, M.K. (2003). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through 2001, (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems. [On line] Available at http://www.drugstrategies.org

ReferencesDennis, M.L. & White,M.A. (2003). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through

2002. Washington, DC: Drug Strategies. Retrived from www.drugstrategies.com . Funk, R. R., McDermeit, M., Godley, S. H., & Adams, L. (2003). Maltreatment issues by level of adolescent substance abuse treatment

The extent of the problem at intake and relationship to early outcomes. Journal of Child Maltreatment, 8, 36-45.Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. (2002). Preliminary outcomes from the assertive continuing care

experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment, 23, 21-32.Godley, M., Godley, S., Dennis, M., Funk, R. & Passetti, L. (2002). Findings from the Assertive Continuing Care Experiment.

Presentation at the American Public Health Association annual conference, Philadelphia, PA November 11, 2002. Hser, Y., Grella, C. E., Hubbard, R. L., Hsieh, S. C., Fletcher, B. W., Brown, B. S., & Anglin, M. D. (2001). An evaluation of drug

treatments for adolescents in four U.S. cities. Archives of General Psychiatry, 58, 689-695.Lewinsohn, P.M., Hops, H., Roberts, R.E., Seeley, J.R., Andrews, J.A. (1993). Adolescent psychopathology, I: prevalence and

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

Washington, DC: National Academy Press.Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD: Substance Abuse

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

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

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

and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statisticsTims, F. M., Dennis, M. L., Hamilton, N., Buchan, B. J., Diamond, G. S., Funk, R., & Brantley, L. B. (2002). Characteristics and

problems of 600 adolescent cannabis abusers in outpatient treatment . Addiction, 97, 46-57.Titus, J. C., Dennis, M. L., White, W. L., Scott, C. K., & Funk, R. R. (2003). Gender differences in victimization severity and outcomes

among adolescents treated for substance abuse. Journal of Child Maltreatment, 8, 19-35.

Contact Information

Michael L. Dennis, Ph.D., Senior Research PsychologistLighthouse Institute, Chestnut Health Systems720 West Chestnut, Bloomington, IL 61701Phone: (309) 827-6026, Fax: (309) 829-4661E-Mail: [email protected]

what works: advances in adolescent substance abuse treatment and research michael dennis, ph.d....

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