Implementing Evidenced Based Substance Abuse Services for Adolescents

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

Presentation at “NEW DIRECTIONS TO HEALTHIER COMMUNITIES & METH SUMMIT”, September 28-30, 2005, Savannah Marriott Riverfront, Savannah, GA. Sponsored by the Georgia Council on Substance Abuse and the Georgia Department of Juvenile Justice, Office of Behavioral Health Services. 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 using data provided by the following grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888, TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340, TI130022, TI03345, TI012208, TI013323, TI14376, TI14261, TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272, TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678, TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674, TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514, TI15672, TI15478, TI15447, TI15545, TI15671)). 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]

Goals of this Presentation

    

Provide a brief introduction on the move to evidenced based practice (ECP) Summarize the recent growth in adolescent substance abuse treatment and research Discuss the infrastructure and organizational changes that are typically required to shift to evidence based practice Review the materials that are currently available to support evidence based practice, Introduce a common data set of adolescent treatment programs using the Global Appraisal of Individual Needs (GAIN) that is being used by CSAT’s adolescent grantees and which has provided data to support the planning of many of recent papers and presentations

Context

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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

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reduce substance use and its negative consequences among those who are abusing or dependent,

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reduce the likelihood of relapse for those who are recovering, and reduce risks for initiating drug use among those not yet using, NIDA Blue Ribbon Panel on Health Services Research (see www.nida.nih.gov

)

General Behavioral Health Practice

   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 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

Problems and Barriers in SA Tx

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

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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

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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

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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 best practices

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

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

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They are an efficient and logical place to start

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But they can be limited or biased and need to be combined with other information

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Just because the person does not know something (or the RCT has not be done), does not mean it is not so

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Synthesizing them with other information usually makes them better

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

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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

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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

What are the pitfalls of EBP?

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EBP generally causes some staff turnover

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EBP often shines a light on staff or work place problems that would otherwise be ignored

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EBP often impact a wide range of existing procedures and policies – requiring modification and provoking resistance

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EBP (and most organizational changes) will fail without good senior staff leadership

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EBP typically require going for more funds from grant or other funders

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On-going needs assessment will create demand for more change and more EBP

Growing Infrastructure

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Increasing availability and use of standardized assessment to help focus and improve clinical practice Growing number of manualized protocols designed for replication and use in practice CSAT increasingly encouraging and/or requiring the use of standardized assessment, manuals, training, and quality assurance practices to ensure adherence ATTCs collaborating with CSAT, NIDA and NIAAA to train individual staff Growing Literature GAIN/ JMATE workgroups (Gender, Spanish, African American, Asian, LGBT, Juvenile Justice, Comorbidity, Strength Based, Substance-specific, Intervention specific, Trainers, Data Managers, MIS, Evaluators )

There is a list of above resources at the end of these handouts

How we are building a common knowledge base about what is working for whom through

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Pooling data across multiple evaluations and programs

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Identifying common factors and principals that appear to hold across interventions

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Having peer reviewed panels review and rate the strength of evidence on the effectiveness and generalizability of specific interventions

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Conducting formal meta analysis of a groups of similar interventions that have been replicated and evaluated several times

Reoccurring Themes…

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Severity and specificity of problem subgroup Manualized and replicable 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)

Global Appraisal of Individual Needs (GAIN)

   – –

The GAIN family of instruments were developed through a 10 year collaboration of researchers, clinicians, policy makers, and IT specialists They provide a standardized approach to measuring: Eligibility/need (i.e., screening), DSM/ICD Diagnosis,

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ASAM level of care Placement, Study/State/Federal Reporting, Treatment Planning,

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Severity/Case Mix, Change in Functioning, Service Utilization, and other Outcomes, and Economic Cost and Benefits of treatment Includes 103 scales and over 2000 created variables, had good reliability/validity, 174 agencies and over four dozen scientists working with it

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

Adolescent and Adult Treatment Program GAIN Clinical Collaborators

Number of GAIN Sites

30 to 60 10 to 29 2 to 9 1 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

The Current Renaissance of Adolescent Treatment Research

                 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)

CSAT AT Program Common Data Set

      

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) All data collected with the Global Appraisal of Individual Needs (GAIN) using centrally trained and certified staff Outcome data through 12 months available on over 90% of CYT and ATM clients and over 80% of others “due” in on-going programs Programs include several standardized protocols based on both research and practice (ACC, ACRA, ATM, FFT, FSN, Matrix, MET/CBT, MDFT, MST) Local evaluations include several experiments and quasi experiments, as well as up to 40 replications of the same manualized protocol in different sites Several workgroups working on common themes across programs (African American, Co-morbidity, Family, Native American/Indian, Spanish translation/workforce) Data being shared for meta and several secondary analyses

CSAT Adolescent Treatment (AT) Programs Reordered by Level of Care and Severity

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EAT: Effective Adolescent Treatment (2003-2007; n=975)

replicating the CYT MET/CBT intervention in early intervention, school and outpatient settings(22 of 36 grants: Bradley, Brown, Clayton,Curry, Davis, Dillon, Dodge, Kressler, Kincaid, Levine, Levy, Locario, Mason, Moore, Rajaee-Moore, Paull, Payton, Rezende, Taylor, Tims, Turner, Vincent)

CYT: Cannabis Youth Treatment (1997-2001; n=600)

Experiments with adolescent outpatient/intensive outpatient (5 grants: Babor, Dennis, Diamond, Godley, Tims)

TCE: Targeted Capacity Expansion (2002-2007; n=189)

evaluation of intensive outpatient programs and some residential treatment (2 of 12 grants: Tims, Lloyd)

SCY: Strengthening Communities-Youth (2002-2007; n=1120)

evaluations of early intervention, outpatient, intensive outpatient and some residential (11 of 12 grants: Beach, Bolland, Dahl, Gerstel, Godley, Hall, Hutchinson, Keehn, Murphy, Noonan, Panzarella)

ATM: Adolescent Treatment Model (1998-2002; n=1468)

short and long term residential (10 grants: Batttjes, Fishman, Godley, Liddle, Morral, Perry, Sabin, Shane, Stevens-2) evaluations of outpatient,

ART: Adolescent Residential Treatment (2003-2006; n=1179)

evaluations of residential treatment enhancements and continuing care (17 grants: Beach, Fishman, Flores, Gay, Gnazzo, Hatch, Hurtig, Lane, Law, Manov, May, Miley, Nordquist, Snipes, Urquahart, Whitmore, Zammarelli)

Level of Care

100% 80% 60% 40% 20% 0% EAT CYT TCE SCY ATM ART Total Other Resid. Continuing Care Long Term Residential Med. Term Residential Short Term Residential Intensive Outpatient Outpatient Early Intervention

Source: CSAT 2004 AT Common GAIN Data set

Gender

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY ATM

Source: CSAT 2004 AT Common GAIN Data set

ART Total Male Female

While few individual studies can break out females, this data set has 1497 (so far)

Race

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY ATM ART Total

Source: CSAT 2004 AT Common GAIN Data set

Other Mixed Native American/ Alaskan Hispanic Caucasian/White Asian/Pacific Islander African American

Across sites there are 300 or more for all subgroups but Asian (so far)

Age

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY

Source: CSAT 2004 AT Common GAIN Data set

ATM ART Total 21-25 18-20 15-17 0-14

921 Under 14 and 377 young adults

Other Characteristics

Single Parent Homeless or Runaway Employed In School Juvenile Justice Involvement Recently in a Controlled Environment

Source: CSAT 2004 AT Common GAIN Data set

39% 34% 50% 45% 70% 86%

Years of Use

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY

Source: CSAT 2004 AT Common GAIN Data set

ATM ART Total 5+ Years 3-4 Years 1-2 Years Less than 1

Substance Use Severity (based on self-report)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY

Source: CSAT 2004 AT Common GAIN Data set

ATM ART Total Dependence Abuse Subclinical use/problems

Weekly/Daily Substance Use Pattern

Any AOD Use Marijuana Alcohol 20% Cocaine/Crack 5% Heroin/Opioids 3% Other Drugs 14 or more days in Controlled Environment 8% 30%

Source: CSAT 2004 AT Common GAIN Data set

52% 65% 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

Prior Substance Abuse Treatment

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY

Source: CSAT 2004 AT Common GAIN Data set

ATM ART Total Two or more One None

Mixed Problem Recognition

Acknowledges AOD problem Believes treatment needed Self reports meets abuse/dependence criteria Gives one or more reasons to quit

Source: CSAT 2004 AT Common GAIN Data set

35% 81% 92% 99%

High Risk Recovery Environments

In home among work/ school peers among social peers In home among work/ school peers among social peers 17% 29%

Source: CSAT 2004 AT Common GAIN Data set

52% 61% 67% 79%

Patterns of Co-Occurring Disorders

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY

Source: CSAT 2004 AT Common GAIN Data set

ATM ART Total Both Internal & External Disorders External Disorder(s) Only Internal Disorder(s) only Neither

Interventions need to be more specific

Any Internal Disorder

Depressive Disorder 38% Anxiety Disorder Trauma Related Disorder Any Self Mutilation Any homicidal/ suicidal thoughts

Any External Disorder

Conduct Disorder Attention Deficit-Hyperactivity Disorder (ADHD)

Source: CSAT 2004 AT Common GAIN Data set

21% 28% 32% 28% 49% 48% 59% 67% Within a diagnosis there are also mild to severe subgroups

Also High Rates of HIV/STI risk behaviors

Sexual Activity Victimization Needle Use Sexual Activity Sex Under AOD Influence Multiple Sex Partners Unprotected Sex Victimization Needle Use 4% 16% 35% 29% 23% 57% 51% 61%

Source: CSAT 2004 AT Common GAIN Data set

81%

Severity of Victimization History

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY

Source: CSAT 2004 AT Common GAIN Data set

ATM ART Total High (4-15 on General Victimization Scale [GVS] *) Moderate (Any Lifetime, 1-3 on GVS*) Low (No History) * Based on lifetime history and current fear of 4 types of victimization (attached with a weapon, beaten, sexually assaulted, emotionally abused), and 8 trauma factors (under 18, someone trusted, multiple people, multiple times, sexual penetration, fear for life, no one believed when reported)

Victimization interacts with MH problems

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Low Moderate High 

Severity of Victimization



Source: CSAT 2004 AT Common GAIN Data set

Total Both Internal & External Disorders External Disorder(s) Only Internal Disorder(s) only Neither

Intensity of Juvenile Justice System Involvement

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY

Source: CSAT 2004 AT Common GAIN Data set

ATM ART Total In detention/ jail 14+ days On prob./ parole 14+ days w/ 1+ drug screens Other probation, parole, detention Other JJ status Past arrest/ JJ status Past year illegal activity/SA use

It is NOT just about possession… Past Year

Any violence or illegal activity Physical Violence Property Crimes Drug Related Crime Interpersonal Crimes

Source: CSAT 2004 AT Common GAIN Data set

58% 57% 51% 72% 86%

Need to focus on multiple problems clients

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EAT CYT TCE SCY

Source: CSAT 2004 AT Common GAIN Data set

ATM ART Total

Number of 12 Major Clinical Problems*

5 or more Problems 4 Problems 3 Problems 2 Problems 1 Problem * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Generalizability of research focused on a single problem

Victimization is particularly intertwined with the number of problems*

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 Problem Low 2 Problems Mod.

High 3 Problems 4 Problems 5 or more Problems (117.2) * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

Source: CSAT 2004 AT Common GAIN Data set (odds for High over odds for Low)

Victimization Also Interacts with Outcomes

25 20 15

CHS Outpatient CHS Residential

40

Traumatized groups

35

have higher severity

30 10 5

High trauma group does not respond to OP

0 Intake 6 Months OP -High Source: Funk, et al., 2003 OP - Low/Mod Intake Resid-High

Both groups respond to residential treatment

6 Months Resid - Low/Mod.

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

1.00

0.80

0.60

0.40

0.20

Other programs serve clients who have significantly higher severity

CYT Total (n=217; d=0.51) ATM Total (n=284; d=0.41) CHSOP (n=57; d=0.18) 0.00

-0.20

And on average they have moderate effect sizes even with high GVS

-0.40

-0.60

-0.80

-1.00

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

Intake Mon 1-3 Mon 4-6 Mon 7-9 Source: CYT and ATM Outpatient Data Set Mon 10-12

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

The two best were used with much higher severity adolescents and TDC was not manualized

-0.80

-1.00

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

Intake Mon 1-3 Source: CYT and ATM Outpatient Data Set Mon 4-6 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) Mon 7-9 Mon 10-12

Which 5 OP Programs, of similar severity, 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

Trying MET/CBT5 because it is stronger, cheaper, and easier to implement

-0.80

-1.00

Not much improvement and they do not work quite as well

Intake Mon 1-3 Source: CYT and ATM Outpatient Data Set Mon 4-6 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) Currently CHS is doing an experiment comparing its regular OP with MET/CBT5 Mon 7-9 Mon 10-12

Areas where staff wanted more specific knowledge and interventions

            

Victimization, trauma and helplessness Self mutilation, para-suicidal and suicidal behaviors Anger management, violence and crime How to help their kids access mental health services (typically for internal disorders) when availability is limited Managing ADHD and impulsivity How to get parents involved in treatment and continuing care Tobacco, opioids, and methamphetamine use, Working with schools, probation, families Females, Males, African Americans, Native Americans, Spanish Speaking adolescents and their families HIV, STI, and Liver risk How to make interventions more assertive and strength based Evaluation issues like follow-up, data management, & analysis Workforce development, including peer-to-peer on specific treatment approaches and other job functions like MIS

Common Strategies you can do NOW

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Standardize assessment and identify most common problems

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Pool knowledge about what staff have done in the past, whether it worked, and what the barriers were

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Identify system barriers (e.g., criteria to local access case management, mental health) that could be avoided if thought of in advance

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Identify existing materials that could help and make sure they are readily available on site

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Identify promising strategies for working with the adolescent, parents, or other providers

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Develop a 1-2 page checklist of things to do when this problem comes up

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Identify a more detailed protocol and trainer to address the problem, then go for a grant to support implementation

Resources

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Assessment Instruments

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CSAT TIP 3 at

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

NIAAA Assessment

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Handbook,http://www.niaaa.nih.gov/publications/instable.htm GAIN Coordinating Center www.chestnut.org/li/gain

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Treatment Programs

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CSAT CYT, ATM, ACC and other treatment manuals at www.chestnut.org/li/apss/csat/protocols or www.chestnut.org/li/bookstore SAMHSA at http://kap.samhsa.gov/products/manuals/cyt/index.htm or 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

Resources



Implementing Evidenced based practice

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

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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

2005 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/csatsasatepost/ Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) www.chestnut.org/li/apss/sasate

References Cited Here

Beutler, L. E. (2000). David and Goliath When empirical and clinical standards of practice meet. American Psychologist, 55, 997-1007.

Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28 (2S), S49-S60 .

Dennis, M.L., & White, M.K. (2003). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through 2001, (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems. [On line] Available at http://www.drugstrategies.org Dennis, M. L. and White, M. K. (2004). Predicting residential placement, relapse, and recidivism among adolescents with the GAIN. Poster presentation for SAMHSA's Center for Substance Abuse Treatment (CSAT) Adolescent Treatment Grantee Meeting; Feb 24; Baltimore, MD. 2004 Feb.

White, M. K., Funk, R., White, W., & Dennis, M. (2003). Predicting violent behavior in adolescent cannabis users The GAIN-CVI. Offender Substance Abuse Report, 3(5), 67-69.

White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2), 24-28.