Transcript Insert Workshop Title

Cannabis Youth Treatment Experiment:
12 and 30 Month Main Findings
Michael Dennis, Ph.D.
(On Behalf of the
CYT Steering Committee)
Chestnut Health Systems
Bloomington, IL
Presentation at CSAT Pre-Session at the
College of Problems on Drug
Dependence, 65th Annual Scientific
Meeting, June 13, 2003, Bal Harbour,
Florida. Available from author at
www.chestnut.org/li/posters,
[email protected] or 309-827-6026.
Acknowledgement
This presentation is based on the work, input and contributions from several
other people including: Nancy Angelovich, Tom Babor, Laura (Bunch)
Brantley, Joseph A. Burleson, George Dent, Guy Diamond, James Fraser,
Michael French, Rod Funk, Mark Godley, Susan H. Godley, Nancy
Hamilton, James Herrell, David Hodgkins, Ronald Kadden, Yifrah Kaminer,
Tracy L. Karvinen, Pamela Kelberg, Jodi (Johnson) Leckrone, Howard
Liddle, Barbara McDougal, Kerry Anne McGeary, Robert Meyers, Suzie
Panichelli-Mindel, Lora Passetti, Nancy Petry, M. Christopher Roebuck,
Susan Sampl, Meleny Scudder, Christy Scott, Melissa Siekmann, Jane Smith,
Zeena Tawfik, Frank Tims, Janet Titus, Jane Ungemack, Joan Unsicker,
Chuck Webb, James West, Bill White, Michelle White, Caroline Hunter
Williams, the other CYT staff, and the families who participated in this study.
This presentation was supported by funds and data from the Center for
Substance Abuse Treatment (CSAT’s) Persistent Effects of Treatment Study
(PETS, Contract No. 270-97-7011) and the Cannabis Youth Treatment (CYT)
Cooperative Agreement (Grant Nos. TI11317, TI11320, TI11321, TI11323,
and TI11324). The opinions are those of the author and steering committee
and do not reflect official positions of the government .
CYT
Cannabis Youth Treatment
Randomized Field Experiment
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
Marijuana
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Use is starting at younger ages
Is at an historically high level among adolescents
Potency increased 3-fold from 1980 to 1997
Is three times more likely to lead to dependence
among adolescents than adults
Is associated with many health, mental and
behavioral problems
Is the leading substance mentioned in adolescent
emergency room admissions and autopsies
Treatment
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Marijuana related admissions to adolescent substance
abuse treatment increased by 115% from 1992 to
1998
Over 80% of adolescents entering treatment in 1998
had a marijuana problem
Over 80% are entering outpatient treatment
Over 75% receive less than 90 days of treatment
(median of 6 weeks)
Evaluations of existing adolescent outpatient
treatment suggest that last than 90 days of outpatient
treatment is rarely effective for reducing marijuana
use.
Purpose of CYT
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To learn more about the characteristics and needs of
adolescent marijuana users presenting for outpatient
treatment.
To adapt evidence-based, manual-guided therapies for
use in 1.5 to 3 month adolescent outpatient treatment
programs in medical centers or community based
settings.
To field test the relative effectiveness, cost and costeffectiveness of five interventions targeted at
marijuana use and associated problems in adolescents.
To provide validated models of these interventions to
the treatment field in order to address the pressing
demands for expanded and more effective services.
Design
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Target Population: Adolescents with marijuana disorders
who are appropriate for 1 to 3 months of outpatient treatment.
Inclusion Criteria: 12 to 18 year olds with symptoms of
cannabis abuse or dependence, past 90 day use, and meeting
criteria for outpatient treatment
Data Sources: self report, collateral reports, on-site and
laboratory urine testing, therapist alliance and discharge
reports, staff service logs, and cost analysis.
Random Assignment: to one of three treatments within site
in two research arms and quarterly follow-up interview for 12
months
Long Term Follow-up: under a supplement from PETSA
follow-up was extended to 30 months (42 for a subsample)
Two Experiments or Study Arms
Experiment 1
Incremental Arm
Experiment 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)
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
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
sessions of
group
Multi-Family
group
Multi-Participant
Group
5
Participant only
0
MET/
CBT5
MET/
CBT12
MET/
CBT12 +
FSN
Incremental Arm
Source: Dennis et al, under review
MET/
CBT5
ACRA
MDFT
Alternative Arm
Average Episode Cost ($US) of Treatment
Average Cost Per Client-Episode of Care
|--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----|
$4,000
Less thanLess than
average average
for 6 weeks
for 12 weeks
$3,322
$3,500
$3,000
$3,495
$2,500
$1,984
$1,776
$2,000
$1,559
$1,500
$1,126
$1,197
$1,000
$500
$-
Source: French et al., 2002
$1,413
Implementation of Evaluation
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Over 85% of eligible families agreed to participate
Quarterly follow-up of 94 to 98% of the adolescents from 3- to
12-months (88% all five interviews)
Long term follow-up completed on 90% at 30-months and 91%
(of 116 subsample) at 42-months
Collateral interviews were obtained at intake, 3- and 6-months
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).
Self report marijuana use largely in agreement with urine test at
30 months (13.8% false negative, kappa=.63)
5 Treatment manuals drafted, field tested, revised, send out for
field review, and finalized (10-30,000 copies of each already
printed and distributed)
Descriptive, outcome and economic analyses completed
Source: Dennis et al, 2002, under review
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)
Source: Tims et al, 2002
Prior
T reatment
TE DS Outpatient (n=16,480)
* Adolescents w ith m arijuana problem s adm itted to outpatient treatm ent
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
Institutional Involvement
100%
87%
80%
62%
60%
47%
40%
25%
20%
0%
In school
Source: Tims et al, 2002
Employed
Current CJ
Involvement
Coming from
Controlled
Environment
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
Multiple Problems are the NORM
Self-Reported in Past Year
0%
20%
40%
60%
80% 100%
86%
Any Marijuana Use Disorder
37%
Any Alcohol Use Disorder
Other Substance Use Disorders
Any Internal Disorder
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, under review
Co-occurring Problems are Higher for those
Self-Reporting Past Year Dependence
100%
80%
71%
57%
60%
42%
40%
37%
30%
25%
22%
22%
20%
13%
5%
0%
Health Problem
Distress*
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)
* p<.05
Evaluating the Effects of Treatment
Treatment Outcome
Long Term Stability
Difference between intake and
Difference between average of short term
average of all short term
follow-ups (3-12) and long term follow-up (30)
follow-ups (3-12)
Month
0.00
Z-Score
-0.10
-0.20
-0.30
-0.40
-0.50
-0.60
Short Term Outcome Stability
Difference between average of
early (3-6) and latter (9-12)
follow-up interviews
Source: Dennis et al, under review, forthcoming
Freq. of Use
Sub. Prob.
Change in Substance Frequency Scale in
Frequency Index
CYT Experiment 1:Substance
Incremental
Arm
Incremental Arm
0.25
Treatment Outcome:
-Use reduced (-34%)
- No Sig. Dif. by condition
0.20
MET/CBT5
MET/CBT12
FSN
0.15
0.10
0.05
0.00
0
3
6
Short Term Stability:
- Outcomes stable (-1%)
- No Sig. Dif. by condition
Source: Dennis et al, forthcoming
9
12
15
18
Months from Intake
21
24
27
30
Long Term Stability:
- Use increases (+64%)
- No Sig. Dif. by condition
Change in Number of Substance Problems in
PastIncremental
Month Substance Problems
CYT Experiment 1:
Arm
Incremental Arm
5
4
Treatment Outcome:
-Problems reduced (-46%)
- Sig. Dif. by condition
(-50% vs. –33% vs. –51%)
MET/CBT5
MET/CBT12
FSN
3
2
1
0
0
3
6
9
12
15
18
21
24
27
30
Long Term Stability:
Short Term Stability:
-Problems increase (+17%)
-Further reductions (-25%) Months from Intake
-Sig. Dif. by condition
- No difference by condition
(+37% vs +10% vs +7%)
Source: Dennis et al, forthcoming
Change in Substance Frequency Scale in
Substance Frequency Index
CYT Experiment 2: Alternative
Arm
Alternative Arm
0.25
0.20
Treatment Outcome:
- Use reduced (-35%)
- No Sig. Dif. by condition
MET/CBT5
ACRA
MDFT
0.15
0.10
0.05
0.00
0
3
6
9
Short Term Stability:
-Further reductions (-6%)
- Sig. Dif. by condition
(+4% vs. –10% vs. –11%)
Source: Dennis et al, forthcoming
12
15
18
Months from Intake
21
24
27
30
Long Term Stability:
- Outcomes stable (+20%)
-No Sig. Dif. by condition
Change in Number of Substance Problems in
PastAlternative
Month Substance Problems
CYT Experiment 2:
Arm
Alternative Arm
5
4
Treatment Outcome:
- Problems reduced (-43%)
- No difference by condition
MET/CBT5
ACRA
MDFT
3
2
1
0
0
3
6
9
12
15
18
Short Term Stability:
- Outcomes stable (-8%) Months from Intake
- No Sig. Dif. by condition
Source: Dennis et al, forthcoming
21
24
27
30
Long Term Stability:
- Outcomes stable (+7%)
-No Sig. Dif. by condition
Percent in Past Month Recovery
(no use or problems while living in the community)
50%
40%
30%
18%
20%
17%
14%
14%
11%
10%
6%
0%
0 3 6 9 12 30
MET/ CBT5
0 3 6 9 12 30
MET/ CBT12
Source: Dennis et al, forthcoming
0 3 6 9 12 30
FSN
0 3 6 9 12 30
MET/ CBT5
0 3 6 9 12 30
ACRA
0 3 6 9 12 30
MDFT
Cumulative Recovery Pattern at 30 months:
(The Majority Vacillate in and out of Recovery)
5% Sustained
Recovery
37% Sustained
Problems
19% Intermittent,
currently in
recovery
39% Intermittent,
currently not in
recovery
Source: Dennis et al, forthcoming
Recovery (CPPR)
Cost Per Person in
Cost Per Person in Recovery at 12 and 30
Months After Intake by CYT Condition
Stability of
Experiment 1 (n=299)
MET/CBT-5MET/CBT-5,
findings
-12
$30,000
mixed at 30and
months
ACRA more
$25,000
$20,000
Experiment 2 (n=297)
cost effective at
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., under review; forthcoming
Integrated family therapy (MDFT)
was more cost effective than adding
it on top of treatment (FSN) at 30
months
Reduction in Average Cost to Society in
CYT Experiment 1: Incremental Arm
Includes the
cost of CYT
Treatment
Reductions
(-23%) in Average
Cost to Society
offset Treatment
Costs within 12
months
Source: French et al, in press; forthcoming
Further
Reductions
(-47%)
occurred out to
30 months
Reduction in Average Cost to Society in
CYT Experiment 2: Alternative Arm
Includes the
cost of CYT
Treatment
Average Cost to
Society goes up
then down and
does not offset Tx
Costs within 12
months (+7%)
Source: French et al, in press; forthcoming
Further
Reductions
occurred out to
30 months
(-40%)
Average Cost to Society Varied
More by Site than Condition
UCHC, Farmington, CT (-24%, -44%)
$6,000
PAR, St. Petersburg, FL (-22%, -49%)
CHS, Madison Co., IL (-8%, -51%)
$5,000
CHOP, Philadelphia, PA (+18%, -34%)
$4,000
$3,000
$2,000
$1,000
$0
0
3
6
9
Source: French et al, in press; forthcoming
12
15
18
Months from Intake
21
24
27
30
Reprise of Clinical Outcomes
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Co-occurring problems were the norm and varied with
substance use severity.
Most of the treatment effects came during active phase
of treatment and were sustained or improved during the
12 months of initial follow-up; though longer term
follow-up suggests that some ground was lost.
While there were some effects of treatment type, these
were not easily explained by dosage or level of family
therapy and produced only minor improvements.
While more effective than many earlier outpatient
treatments, 2/3rds of the CYT adolescents were still
having problems 12 months latter, 4/5ths were still
having problems 30 months latter.
Reprise of Economic Outcomes
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There were considerable differences in the cost of
providing each of the interventions.
MET/CBT-5, -12 and ACRA were the most cost
effective at 12 months, though the stability of the
MET/Findings were mixed at 30 months.
Reductions in Average Quarterly Cost to Society
offset the cost of treatment within 12 months in
experiment 1 and with 30 months in experiment 2.
At 12 months the MET/CBT5 intervention clearly
had the highest rate of return, though it was less
likely to have “additional” benefits at 30 months
Results of clinical outcomes, cost-effectiveness, and
benefit cost were different – suggesting the
importance of multiple perspectives
Impact and Next Steps
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Papers published on design, validation, characteristics,
matching, clinical contrast, treatment manuals,
therapist reactions, 6 month outcomes, cost, benefit
cost
Papers with main findings at 12 months under review
and 30 month findings being submitted this summer.
Interventions being replicated as part of over two
dozen studies currently or about to go into the field
Over 10-30,000 copies of each of 5 manuals
distributed to policy makers, providers, individual
clinicians and training programs
Source: Dennis et al, 2002, under review
Implications
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The CYT interventions provide replicable models of
brief (1.5 to 3 month) treatments that can be used to
help the field maintain quality while expanding
capacity.
While a good start, the CYT interventions were still not
an adequate dose of treatment for the majority of
adolescents.
The majority of adolescents continued to vacillate in
and out of recovery after discharge from CYT.
More work needs to be done on providing a continuum
of care, longer term engagement and on going recovery
management.
Contact Information
Michael L. Dennis, Ph.D., CYT Coordinating Center PI
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Manuals and Additional Information are Available at:
CYT:
www.chestnut.org/li/cyt/findings or
www.chestnut.org/li/bookstore
NCADI: www.health.org/govpubs
PETSA: www.samhsa.gov/centers/csat/csat.html
(then select PETS from program resources)