Transcript Insert Workshop Title

Adolescent Addiction:
Research and Treatment
Michael Dennis, Ph.D.
Chestnut Health Systems,
Bloomington, IL
Presentation on October 30, 2008 at a conference sponsored by the Council on Chemical Abuse in cooperation with Community
Care Behavioral Health Organization (CCBH), the Berks County Mental Health/Mental Retardation Program, Berks County
Children and Youth Services, the Substance Abuse Service Providers Association of Berks County, and the PA Department of
Health/Bureau of Drug and Alcohol Program, Sheraton Reading Hotel, Wyomissing, 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]
This Presentation Will Examine
1. The Cannabis Youth Treatment (CYT)
Experiments and its Replications
2. The Adolescent Treatment Model (ATM)
studies
3. CSAT Actuarial Estimates of NOMS
outcomes to improve placement
4. The Assertive Continuing Care (ACC)
experiment
2
CYT
Cannabis Youth Treatment
Randomized Field Trial
Coordinating Center:
Chestnut Health Systems, Bloomington, IL,
and Chicago, IL
University of Miami, Miami, FL
University of Conn. Health Center, Farmington, CT
Sites:
Univ. of Conn. Health Center, Farmington, CT
Operation PAR, St. Petersburg, FL
Chestnut Health Systems, Madison County, IL
Children’s Hosp. of Philadelphia, Phil. ,PA
Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA), U.S. Department of Health and Human Services
Context Circa 1997

Cannabis had become more potent, was associated with a
wide of problems (particularly when combined with alcohol),
and had become the leading substances mentioned in arrests,
emergency room admissions, autopsies, and treatment
admissions (doubling in in 5 years)

Over 80% of adolescents with Cannabis problems were being
seen in outpatient setting

The median length of stay was 6 weeks, with only 25%
making it 3 months

There were no published manuals targeting adolescent
marijuana users in outpatient treatment

The purpose of CYT was to manualize five promising
protocols, field test their relative effectiveness, cost, and
benefit-cost and provide them to the field
Source: Dennis et al, 2002
4
Two Effectiveness Experiments
Trial 1
Incremental Arm
Trial 2
Alternative Arm
Randomly Assigns to:
Randomly Assigns to:
MET/CBT5
MET/CBT5
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (12 weeks)
FSN
Family Support Network
Plus MET/CBT12 (12 weeks)
Source: Dennis et al, 2002
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
ACRA
Adolescent Community
Reinforcement Approach(12 weeks)
MDFT
Multidimensional Family Therapy
(12 weeks)
5
Contrast of the Treatment Structures
MET/
CBT5
MET/
CBT12
FSN
ACRA
MDFT
Individual Adolescent Sessions
2
2
2
10
6
CBT Group Sessions
3
10
10
2
3
2
6
22
14
15
As
needed
As
needed
As
needed
Type of Service
Individual Parent Sessions
Family Sessions/Home Visits
4
Parent Education Sessions
6
Total Formal Sessions
5
12
Case management/
Other Contacts
Total Expected Contacts
5
12
22+
14+
15+
Total Expected Hours
5
12
22+
14+
15+
Total Expected Weeks
6-7
12-13
12-13
12-13
12-13
Source: Diamond et al, 2002
6
Actual Treatment Received by Condition
ACRA and MDFT
both rely on
individual, family and
case
management
And
MDFT
instead
using
moreof group
14
family therapy
With ACRA
using more
11
individual
therapy
23
10
10
5
5
Case
Management
Family
Counseling
Collateral only
Days
Hours
25
FSN adds multi
family group,
family
20 home visits
and more case
MET/CBT12
adds 7 management
more
15 of
sessions
group
Multi-Family
group
Multi-Participant
Group
5
Participant only
0
MET/
CBT5
MET/
CBT12
MET/
CBT12 +
FSN
Incremental Arm
Source: Dennis et al, 2004
MET/
CBT5
ACRA
MDFT
Alternative Arm
7
Average Cost Per Client-Episode of Care
Average Episode Cost ($US) of Treatment
$4,000
$3,500
$3,000
Integrating
|--------------------------------------------Economic Cost-------------------------------------------|-------Director Estimate-----|
family therapy
was
less
Less
than
Less than
$3,495
$3,322
expensive
average
average
adding
forthan
6 weeks
for 12it weeks
$2,500
$1,984
$1,776
$2,000
$1,559
$1,500
$1,126
$1,413
$1,197
$1,000
$500
$-
Source: French et al., 2002
8
Implementation of Evaluation

Over 85% of eligible families agreed to participate

Quarterly follow-up of 94 to 98% of the adolescents from 3to 12-months (88% all five interviews)

Collateral interviews were obtained at intake, 3- and 6months on over 92-100% of the adolescents interviewed

Urine test data were obtained at intake, 3, 6, 30 and 42
months 90-100% of the adolescents who were not
incarcerated or interviewed by phone (85% or more of all
adolescents).

Long term follow-up completed on 90% at 30-months

Self reported marijuana use largely in agreement with
urine test at 30 months (13.8% false negative, kappa=.63)

Good reliability (alphas over .85 on main scales) and
correlations with collateral reports (r=.4 to .7)
Source: Dennis et al, 2002, 2004
9
Adolescent Cannabis Users in CYT were
as or More Severe Than Those in TEDS*
% of A dm issions.
100%
85%
80%
78%
71%
60%
47%
46%
40%
26%
26% 26%
20%
0%
First used
under age
15
D ependence W eekly or
more use at
intake
CYT Outpatient(n=600)
Prior
T reatment
TE DS Outpatient (n=16,480)
* Adolescents w ith m arijuana problem s adm itted to outpatient treatm ent
Source: Tims et al, 2002
10
Demographic Characteristics
100%
83%
80%
62%
55%
60%
40%
50%
30%
17%
15%
20%
0%
Female
Source: Tims et al, 2002
Male
African Caucasian Under 15
American
15 to 16
Single
parent
family
11
Institutional Involvement
100%
87%
80%
62%
60%
47%
40%
25%
20%
0%
In school
Source: Tims et al, 2002
Employed
Current JJ
Involvement
Coming from
Controlled
Environment
12
Patterns of Substance Use
100%
80%
73%
71%
60%
40%
17%
20%
9%
0%
Weekly
Tobacco Use
Source: Tims et al, 2002
Weekly Alcohol Significant Time
Weekly
Cannabis Use
Use
in Controlled
Environment
13
Multiple Problems were the NORM
Self-Reported in Past Year
0%
20%
40%
60%
80% 100%
86%
Any Marijuana Use Disorder
Any Alcohol Use Disorder
Other Substance Use Disorders
Any Internal Disorder
37%
12%
25%
Any External Disorder
61%
Lifetime History of Victimization
60%
Acts of Physical Violence
66%
Any (other) Illegal Activity
83%
Three to Twelve Problems
83%
Source: Dennis et al, 2004
14
Substance Use Severity was
Related to Other Problems
100%
80%
71%
57%
60%
42%
40%
37%
30%
25%
22%
22%
20%
13%
5%
0%
Health Problem
Distress*
* p<.05
Acute Mental
Distress*
Acute
Traumatic
Distress*
Past Year Dependence (n=278)
Source: Tims et al 2002
Attention
Deficit
Hyperactivity
Disorder*
Conduct
Disorder*
Other (n=322)
15
90
Days Abstinent
80
Days Abstinent Per Quarter
90%
80%
Percent in Recovery
70
70%
60
60%
50
50%
40
40%
30
30%
20
20%
10
10%
0
0%
Intake
3
6
9
% in Recovery at the End of the Quarter
CYT Increased Days Abstinent
and Percent in Recovery*
12
*no use, abuse or dependence problems in the past month while in living in the community
Source: Dennis et al., 2004
16
Similarity of Clinical Outcomes
by Conditions
Trial 2
Trial 1
300
50%
280
40%
260
30%
240
20%
But better than the
average for OP in220
ATM (200 days of
200
abstinence)
10%
MET/ CBT5
(n=102)
MET/
CBT12
FSN
(n=102)
MET/ CBT5
(n=99)
ACRA
(n=100)
MDFT
(n=99)
Total Days Abstinent*
269
256
260
251
265
257
Percent in Recovery**
0.28
0.17
0.22
0.23
0.34
0.19
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.12
Source: Dennis et al., 2004
Percent in Recovery .
at Month 12
Total days abstinent
over 12 months
.
Not significantly different
by condition.
0%
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.16
17
Moderate to large differences
in Cost-Effectiveness by Condition
$16
$20,000
$16,000
$12
$12,000
$8
$8,000
$4
$4,000
$0
$0
MET/ CBT5
MET/
CBT12
FSN
MET/ CBT5
ACRA
MDFT
CPDA*
$4.91
$6.15
$15.13
$9.00
$6.62
$10.38
CPPR**
$3,958
$7,377
$15,116
$6,611
$4,460
$11,775
* p<.05 effect size f=0.48
** p<.05, effect size f=0.72
Source: Dennis et al., 2004
Cost per person in recovery
at month 12
Cost per day of abstinence
over 12 months
$20
ACRA did better than
MET/CBT5,
and both did
Trial 2
better than MDFT
MET/CBT5 and
Trial 1
12 did better
than FSN
* p<.05 effect size f=0.22
** p<.05, effect size f=0.78
18
Recovery (CPPR)
Cost Per Person in
Cost Per Person in Recovery at 12 and 30
Months After Intake by CYT Condition
Stability of
Trial 1 (n=299)
MET/CBT-5
findings
$30,000 MET/CBT-5, -12
mixed atand
30 months
ACRA more
Trial 2 (n=297)
ACRA Effect
Largely Sustained
$25,000 cost effective at
$20,000
12 months
$15,000
$10,000
$5,000
$0
MET/ CBT5 MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
CPPR at 30 months**
$6,437
$10,405
$24,725
$27,109
$8,257
$14,222
CPPR at 12 months*
$3,958
$7,377
$15,116
$6,611
$4,460
$11,775
* P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months
** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months
Source: Dennis et al., 2003; forthcoming
Integrated family therapy (MDFT)
was more cost effective than adding
it on top of treatment (FSN) at 30
months
19
Change in Quarterly Costs to Society
(12 months minus Intake)
$30,000
No Significant Difference
by Condition
$25,000
Significant Reduction in
Cost to Society Overall
$30,000
$25,000
$20,000
$20,000
$15,000
$15,000
$10,000
$10,000
$5,000
$5,000
$-
$-
$(5,000)
$(5,000)
$(10,000)
$(10,000)
$(15,000)
$(15,000)
Cond
Site: down
4 sig significantly,
reduction,
Three
sitesxwent
2 sig
Incr,
6 no
dif (low power)
one
went
upsig
significantly
$(20,000)
$(25,000)
MET/
CBT5
MET/
CBT12
Source: Dennis et al., 2004
FSN
MET/
CBT5
$(20,000)
$(25,000)
ACRA MDFT Average
20
Environmental Factors are also
the Major Predictors of Relapse
AOD use in the home, family
problems, homelessness, fighting,
victimization, self help group
participation, structure activities
Family
Conflict
-.54
.18
-.13
Family
Cohesion
-.09
Baseline
.32
.77
Recovery
Environment
Risk
.17
.22
.32
.82
.19
Social
Support
-.08
Peer AOD use, fighting,
illegal activity,
treatment, recovery,
vocational activity
The effects of adolescent
treatment are mediated by the
extent to which they lead to
actual changes in the recovery
environment or peer group
Social
Risk
.21
Baseline
.32
Substance
Use
.11
.19
Baseline
.58
.74
.43
SubstanceRelated
Problems
.22
Baseline
Model Fit
CFI=.97 to .99
RMSEA=.04 to .06
Source: Godley et al (2005)
21
Cumulative Recovery Pattern at 30 months
5% Sustained
Recovery
37% Sustained
Problems
19% Intermittent,
currently in
recovery
39% Intermittent,
currently not in
recovery
The Majority of Adolescents
Cycle in and out of Recovery
Source: Dennis et al, forthcoming
22
36 Site Replication on MET/CBT5
WA
NH
MT
VT
ND
OR
MN
ID
WY
WI
SD
UT
CA
AZ
CO
IL
KS
OK
NM
MO
IN
KY
OH
WV VA
NC
TN
AR
LA
MA
RI
CT
NJ
DE
MD
DC
SC
MS AL
TX
AK
PA
IA
NE
NV
NY
MI
ME
GA
CYT: 4 Sites
FL
EAT: 36 Sites
HI
Source: Dennis, Ives, & Muck, 2008
23
Cohen’s d
Range of Effect Sizes (d) for Change in Days
of Abstinence (intake to 12 months) by Site
1.40
1.40
1.20
1.20
1.00
1.00
0.80
0.80
0.60
0.60
0.40
0.40
0.20
0.20
0.00
0.00
4 CYT Sites (f=0.39)
(median within site d=0.29)
Source: Dennis, Ives, & Muck, 2008
36 EAT Sites (f=0.21)
(median within site d=0.49)
24
25
Context Circa 1998-99

Few research studies of existing treatment
programs and no published manuals to support
replication for the few studies that were done

Not clear whether research based treatment
protocols were any better than what the better
programs were already doing

The purpose of ATM was to manualize existing
programs that appeared promising, then to
evaluate them using the same measures and
methods as CYT (allowing quasi-experimental
comparisons)
26
Normal Adolescent Development








Biological changes in the body, brain, and hormonal
systems that continue into mid-to-late 20s.
Shift from concrete to abstract thinking.
Improvements in the ability to link causes and
consequences (particularly strings of events over
time).
Separation from a family-based identity and the
development of peer- and individual-based identities.
Increased focus on how one is perceived by peers.
Increasing rates of sensation seeking/trying new
things.
Development of impulse control and coping skills.
Concerns about avoiding emotional or physical
violence.
27
Key Adaptation for Adolescents

Examples need to be altered
to relevant substances,
situations, and triggers




Consequences have to be
altered to things of concern
to adolescents
Co-morbid problems
(mental, trauma, legal) are
the norm and often
predate substance use

Most adolescents do not
recognize their substance
use as a problem and are
being mandated to
treatment
Treatment has to take into
account the multiple
systems (family, school,
welfare, criminal justice)

Less control of life and
recovery environment

Less aftercare and social
support

Complicated staffing needs
All materials need to be
converted from abstract to
concrete concepts
28
Program Evaluation Data
Level of Care
Clinics Adolescents
1+ FU*
Outpatient/ Intensive
Outpatient (OP/IOP)
8
560
96%
Long Term Residential (LTR)**
4
390
98%
Short Term Residential
(STR)**
4
594
97%
Total
16
1544
97%
* Completed follow-up calculated as 1+ interviews over those due-done, with site varying
between 2-4 planned follow-up interviews. Of those due and alive, 89% completed with 2+
follow-ups, 88% completed 3+ and 78% completed 4.
** Both LTR and STR include programs using CD and therapeutic community models
29
Length of Stay Varies by Level of Care
100%
Long Term Residential (median=154 days; n=222)
Percent Still in Treatment
Short Term Residential (median=31 days; n=589)
Outpatient (median= 88 days; n=554)
About half of those in OP
stay 90 or more days
50%
Source:
390
360
330
300
270
240
210
180
150
120
90
60
Over half
the STR say
more than
30 days
30
0
0%
Length of Stay
Adolescent Treatment Model (ATM) Data
30
Adolescents more likely to transfer
100%
Index Episode of Care (median=52 days; n=1380)
Percent Still in Treatment
System Episode of Care (median=73 days; n=1380)
Length of Stay Across Episodes of
care is about 50% longer
50%
390
360
330
300
270
240
210
180
150
120
90
60
30
0
0%
Length of Stay
Source:
Adolescent Treatment Model (ATM) Data
31
Change in Substance Frequency Scale
by Level of Care\a
Residential programs start more
severe, go down sharply,
but then come back over time
Note the sharp
“hinge” in outcomes
during the active
phase of AOD
treatment
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.32
Change in Substance Problem Scale
by Level of Care\a
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
LTR more
like OP on
symptoms
count
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.33
Percent in Recovery (no past month use or
problems while living in the community)
Longer term
outcomes are
similar on
substance use
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of cares coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.34
Change in Emotional Problem Scale
by Level of Care\a
Note the lack of a hinge;
Effect is generally indirect (via
reduced use) not specific
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.35
Pattern of SA Outcomes is Related to the
Pattern of Psychiatric Multi-morbidity
Number of Past Month
Substance Problems
Multi-morbid Adolescents
start the highest, change the
most, and relapse the most
0
3
6
2+ Co-occurring
1 Co-occurring
No Co-occurring
12
Months Post Intake (Residential only)
Source: Shane et al 2003, PETSA data
36
Change in Illegal Activity Scale
by Level of Care\a
Residential Treatments
have a specific effect
Outpatient Treatments
has an indirect effect
ShortTerm
Resid.
\t,s,ts
LongTerm
Resid
\t,ts
Outpatient
\t,s
\a Source: Adolescent Treatment Model (ATM) data; Levels of care coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.37
CSAT Adolescent Treatment GAIN Data
from 203 level of care x site combinations
Levels of Care
Long-term Residential
Moderate-Term Residential
Short-Term Residential
Source: Dennis, Funk & Hanes-Stevens, 2008
Outpatient Continuing Care
Intensive Outpatient
Outpatient
Early Intervention
General Group Home
Corrections
Other
38
Ratings of Problem Severity (x-axis) by Treatment
Utilization (y-axis) by Population Size (circle size)
Utilization
Average Current Treatment
.
1.00
F. HiHi (CC)
12%
0.80
0.60
0.40
B
Low- Mod
0.20
0.00
C
Mod-Mod
20%
A
Low-Low
D
Hi-Low
8%
12%
-0.20
-0.20
G. Hi-Mod
(Env Sx/
PH Tx)
9%
E
HiMod
14%
14%
H. Hi-Hi
(Intx Sx;
PH/MH Tx)
12%
0.00
0.20
0.40
0.60
0.80
1.00
Average Current Problem Severity
39
Variance Explained in NOMS Outcomes
Percent of Variance Explained
0%
5%
10%
15%
20%
25%
24%
No AOD related Prob.\1
11%
No Health Problems \2
25%
No Mental Health Prob.\2
15%
No Illegal Activity \2
33%
No JJ System Involve. \1
26%
Living in Community \1
18%
No Family Prob. \2
14%
Vocationally Engaged \1
8%
Count of above
\1
Past month
\2
35%
26%
No AOD Use \1
Social Support \2
30%
Past 90 days *All statistically Significant
24%
40
Predicted Count of Positive Outcomes by Level
Predicted Count of Positive Outcomes by Level of Care:
of Care: Cluster
A
Low
Low
(n=1,025)
Cluster A Low - Low (n=1,025)
10
10
9
9
8
8
7
7
6
6
5
5
4
4
3
3
2
2
Outpatient
Higher LOC
41
Best Level of Care*:
Cluster A Low -Best
Low
(n=1,025)
of Care*:
Level
Cluster A Low - Low (n=1,025)
120%
% Best Predicted Outcomes
99.6%
100%
80%
60%
40%
20%
0.4%
0%
Outpatient
Higher LOC
* Based on Maximum Predicted Count of Positive Outcomes
42
Predicted Count of Positive Outcomes by Level
of Care: Cluster C Mod-Mod (n=1209)
10
10
9
9
8
8
7
7
6
6
5
5
4
4
3
3
2
2
Outpatient
Intensive
Outpatient
Outpatient Continuing Care
Residential
43
Best Level of Care*:
of Care*:
Best Level
Cluster C Mod-Mod
(n=1209)
Cluster C Mod-Mod (n=1209)
90%
% Best Predicted Outcomes
80%
70%
60%
50%
40%
38.6%
30.2%
30%
23.6%
20%
7.6%
10%
0%
Outpatient
IOP
OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
44
Predicted Count of Positive Outcomes by Level
of Care: Cluster F Hi-Hi (CC) (n=968)
10
10
9
9
8
8
7
7
6
6
5
5
4
4
3
3
2
2
Outpatient
Intensive
Outpatient
Outpatient Continuing Care
Residential
45
Best Level of Care*:
Level of Care*:
Cluster F Hi-HiBest
(CC)
(n=968)
Cluster F Hi-Hi (CC) (n=968)
90%
81.5%
% Best Predicted Outcomes
80%
70%
60%
50%
40%
30%
20%
10%
9.9%
8.6%
0.0%
0%
Outpatient
IOP
OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
46
Predicted Count of Positive Outcomes by Level
Count ofG.
Positive
Outcomes
by Level
of Care:
of Predicted
Care: Cluster
Hi-Mod
(Env/PH)
(n=749)
Cluster Hi-Mod (Env/PH) (n=749)
10
10
9
9
8
8
7
7
6
6
5
5
4
4
3
3
2
2
Outpatient
IOP/OPCC
Residential
47
Best Level of Care*:
Cluster G Hi-Mod
(n=749)
Level of Care*:
Best(Env/PH)
Cluster G Hi-Mod (Env/PH) (n=749)
100%
94.1%
90%
80%
70%
60%
50%
40%
30%
20%
10%
5.9%
0.0%
0%
Outpatient
IOP/OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
48
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
P not the same in
both directions
Incarcerated
(46% stable)
5%
10%
20%
In the
Community
Using
(75% stable)
7%
Avg of 39% change
status each quarter
12%
3%
More likely than
adults to be diverted
to treatment
(OR=4.0)
24%
In Recovery
(62% stable)
27%
7%
19%
26%
In Treatment
(48% stable)
More likely than adults to stay 90
Source: 2006 CSAT AT data set
days in treatment (OR=1.7)
7%
Treatment is the
most likely path
to recovery
49
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
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)
In the
Community
Using
(75% stable)
12%
In Recovery
(62% stable)
27%
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)
* 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,
50
drugs, fighting, or involved in illegal activity.
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
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)
In the
Community
Using
(75% stable)
7%
In Treatment
(48 v 35% stable)
Source: 2006 CSAT AT data set
51
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
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)
In the
Community
Using
(75% stable)
In Recovery
(62% stable)
26%
19%
In Treatment
(48 v 35% stable)
Source: 2006 CSAT AT data set
* 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.
52
Percent in Past Month Recovery*
Recovery* by Level of Care:
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
CC
better
OP &
Resid
Similar
Pre-Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
* 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)
53
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
Time to Enter Continuing Care and Relapse
after Residential Treatment (Age 12-17)
100%
Percent of Clients
90%
80%
70%
Relapse
60%
50%
Cont.
Care
Admis.
40%
30%
20%
10%
0%
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
55
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)
56
Assertive Continuing Care (ACC)
Hypotheses
Assertive
Continuin
g Care
General
Continuin
g Care
Adherence
Early
Abstinence
Sustained
Abstinence
Relative to UCC, ACC will increase General
Continuing Care Adherence (GCCA)
GCCA (whether due to UCC or ACC) will be
associated with higher rates of early abstinence
Early abstinence will be associated with higher
rates of long term abstinence.
57
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ACC Improved Adherence
Weekly Tx
Weekly 12 step meetings
Relapse prevention*
Communication skills training*
Problem solving component*
Regular urine tests
Meet with parents 1-2x month*
Weekly telephone contact*
Contact w/probation/school
Referrals to other services*
Follow up on referrals*
Discuss probation/school compliance*
Adherence: Meets 7/12 criteria*
Source: Godley et al 2002, 2007
UCC
ACC
* p<.05
58
GCCA Improved Early (0-3 mon.) Abstinence
100%
90%
80%
70%
60%
55%
50%
43%
36%
40%
30%
55%
38%
24%
20%
10%
0%
Any AOD (OR=2.16*)
Low (0-6/12) GCCA
Source: Godley et al 2002, 2007
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Marijuana (OR=1.98*)
* p<.05
59
Early (0-3 mon.) Abstinence Improved
Sustained (4-9 mon.) Abstinence
100%
90%
80%
73%
69%
70%
59%
60%
50%
40%
30%
20%
19%
22%
22%
10%
0%
Any AOD (OR=11.16*)
Alcohol (OR=5.47*)
Early(0-3 mon.) Relapse
Early (0-3 mon.) Abstainer
Source: Godley et al 2002, 2007
Marijuana (OR=11.15*)
* p<.05
60
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.
61
Recommendations for Further Developments…

We need to target the latter phases of treatment to impact the
post-treatment recovery environment and/or social risk
groups that are the main predictors of long term relapse

We need to move beyond focusing on acute episodes of care
to focus on continuing care and a recovery management
paradigm

We need to better understand the impact of involvement in
juvenile justice system and how it can be harnessed to help

More work is need on the use of schools as a location for
providing primary treatment (they have entrée to the
population and appear to be the venue of choice) and
recovery-schools to provide support for those coming out of
residential treatment
62