when the rite of passage goes wrong: what parents should know abuse adolescent drug and alcohol use...

When the Rite of Passage Goes Wrong: What Parents Should Know Abuse Adolescent Drug and Alcohol Use

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

Presentation on October 29, 2008 at a pre-conference session sponsored by the Council on Chemical Abuse in cooperation with Alvernia College and the Caron Treatment Centers in Reading, PA.. 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 448 Wylie Drive, Normal, IL 61761, phone: (309) 451-7801, Fax: (309) 451-7763, 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

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

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 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

Crime & Violence by Substance Severity

0%

10%

20%

30%

40%

50%

60%

Serious FightAt School

Fighting withGroup

Sold Drugs Attacked withintent to harm

Stole (>$50) CarriedHandgun

Dependence (3.9%) Abuse (4.2%)

Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)

Light Alc Use (12.4%) No PY AOD Use (64.3%)

Source: NSDUH 2006

Age 12-17

6

Family, Vocational & MH by Substance Severity

Source: NSDUH 2006

0%

10%

20%

30%

40%

50%

60%

10 or MoreArguments with

Parents

Disliked School GPA = D orlower

MajorDepression

Any MHTreatment

Dependence (3.9%) Abuse (4.2%)

Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)

Light Alc Use (12.4%) No PY AOD Use (64.3%)

Age 12-17

7

1-2 M in 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

1-2 M in 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

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

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

8

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

9Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

10

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

11

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

12

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


13

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

14

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


15

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

16

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

17

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

18

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

19

Past Year Alcohol or Drug Abuse or Dependence

Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

8.8% PA vs.8.9% National

20

Adolescent SUD & Treatment

5.4

5.0

0.3

0.3

5.9

5.5

0.3

0.2

8.9

8.4

0.5

0.4

0

1

2

3

4

5

6

7

8

9

10

U.S. Pennsylvania U.S. Pennsylvania

Abuse or Dependence Treatment

Per

cent

Drug Alcohol Either

Still less than 1 in 15 get treatment

Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

21

2,75

5

4,15

7

5,14

8

6,18

0

6,59

5

6,37

6

5,45

5

5,47

3 6,05

4

5,85

1

5,57

9

5,15

9

6,45

1

5,24

2

5,11

5

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

OP (77%)

IOP (188%)

Residential(110%)

Detox (-41%)

Change in PA Public Treatment Admissions: Level of Care from 1992 to 2006

Source: OAS, 2006 – 1992-2006 TEDS Data

Dramatic Growth in 1992-1997

22% decrease in the past

decade

Decreased use of Detox

22

Change in PA Public Treatment Admissions: Referral Source from 1995 to 2006


-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Other (0%)

Other HealthProvider (49%)

School (-10%)

OtherCommunityReferral (60%)

Other AODProvider (494%)

Self/Family(44%)

Juvenile Justice(129%)

Close link to Juv. Just.

23

Change in PA Public Treatment Admissions: Referral Source from 1995 to 2006


-

1,000

2,000

3,000

4,000

5,000

6,000

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Marijuana (149%)

Alcohol (14%)

Cocaine (89%)

Hallucinogens (-76%)

Opioids (1429%)

Other Stimulants (-24%)

Psychotropics (329%)

Methamphetamine(173%)Other (79%)

Opioid and Psychotropics are less common but growing fast

Marijuana and Alcohol are the most common problems

24

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

25

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

26

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

27

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

Source: Adapted from Lipsey, 1997, 2005

Average Practice

28

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

29

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

30

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

31

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

32

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

33

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

34

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

35

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

36

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

37

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)

38

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

39

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

40

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

41

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)

42

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

Source: CSAT 2007 AT Outcome Data Set (n=12,824)

43

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

44

The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents

In the Community

Using (75% stable)

In Treatment (48% stable)

In Recovery (62% stable)

Incarcerated(46% stable)

5%

12%

7%

20%

24%

10%

26%

7 %

19%7%

27%

3%

Source: 2006 CSAT AT data set

Avg of 39% change status each quarter

P not the same in both directions

Treatment is the most likely path

to recoveryMore likely than adults to stay 90 days in treatment (OR=1.7)

More likely than adults to be diverted

to treatment (OR=4.0)

45

In the Community

Using (75% stable)

12%

27%

Probability of Going from Use to Early “Recovery” (+ good)-Age (0.8) + Female (1.7),- Frequency Of Use (0.23) + Non-White (1.6)

+ Self efficacy to resist relapse (1.4) + Substance Abuse Treatment Index (1.96)

* Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home•** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.

In Recovery(62% stable)

Probability of from Recovery to “Using” (+ bad)+ Freq. Of Use (+5998.00) - Initial Weeks in Treatment (0.97)+ Illegal Activity (1.42) - Treatment Received During Quarter (0.50)+ Age (1.24) - Recovery Environment (r)* (0.69)

- Positive Social Peers (r) (0.70)


46

In the Community

Using (75% stable)

In Treatment

(48 v 35% stable)

7%


Probability of Going from Use to “Treatment” (+ good)-Age (0.7) + Times urine Tested (1.7), + Treatment Motivation (1.6)

+ Weeks in a Controlled Environment (1.4)


47

In the Community

Using (75% stable)

In Treatment

(48 v 35% stable)

In Recovery (62% stable)


26% 19%


Probability of Going to Using vs. Early “Recovery” (+ good)-- Baseline Substance Use Severity (0.74) + Baseline Total Symptom Count (1.46)-- Past Month Substance Problems (0.48) + Times Urine Screened (1.56)-- Substance Frequency (0.48) + Recovery Environment (r)* (1.47)

+ Positive Social Peers (r)** (1.69)

* Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home

** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.

48

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 and is of equal importance

Evidenced based interventions and their outcomes can be replicated in practice

Continuing care and is a key determinant of long term outcomes

when the rite of passage goes wrong: what parents should know abuse adolescent drug and alcohol use...

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