Transcript Insert Workshop Title

The Current Renaissance of
Adolescent Treatment
Michael Dennis, Ph.D.
Chestnut Health Systems,
Bloomington, IL
Presentation for National Conference onBoys & Girls at Risk:The Emerging Science of Gender Differences , Madison, WI July
21-22, 2008. 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 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail:
[email protected]
Goals of this Presentation are to
1. Examine the prevalence, course, and
consequences of adolescent substance use, cooccurring disorders and the unmet need for
treatment overall and by gender
2. Summarize major trends in the adolescent
treatment system and Wisconsin
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 outcome studies on substance abuse
treatment research, trauma and violence/crime
2
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%
No Alcohol or
Drug Use
32%
Light Alcohol
Use Only 47%
Source: 2002 NSDUH
3
Problems Vary by Age
NSDUH Age Groups
100
90
80
Adolescent
Onset
Remission
Increasing
rate of nonusers
70
Severity Category
No Alcohol or Drug Use
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
0
Dependence
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
Source: 2002 NSDUH and Dennis et al forthcoming
4
Higher Severity is Associated with
Higher Annual Cost to Society Per Person
$4,000
Median (50th percentile)
$3,500
Mean (95% CI)
$3,000
$2,500
$2,000
$1,500
$3,058
This includes people who are in
recovery, elderly, or do not use
because of health problems
$1,613
Higher
Costs
$1,528
$1,309
$1,078
$1,000
$725
$406
$500
$0
$948
$0
$0
No
Alcohol or
Drug Use
Light
Alcohol
Use Only
$231
$231
Any
Infrequent
Drug Use
Regular
AOD
Use
Abuse
Dependence
Source: 2002 NSDUH
5
Past Year Alcohol or Drug Abuse or Dependence
Source: OAS, 2006
10.8% Wisc vs.
9.3% National
6
Past Year Alcohol Abuse or Dependence
Source: OAS, 2006
10.6% Wisc vs.
7.7% National
7
Pattern of Teen Substance Use in WI by Gender\a
Lifetime .
0%
10%
Female
18%
Past Month\b
Male
20%
30%
23%
24%
20%
Female 2% 15%
Male 3%
14%
More than
Marijuana
19%
21%
40%
50%
60%
10%
70%
80%
30%
9%
90%
19%
27%
20%
45%
19%
42%
20%
Marijuana
Alcohol
use
Intoxication
\a Each severity level includes any substance to the right
\b More than marijuana is only Cocaine for Past month
Source: Wisconsin 2005 YRBS
100%
Alcohol or
Tobacco Use
Most drug users also
drink to intoxication
No
Use
8
Behavior Problems by Substance Severity in WI\a
Behavior Problems by Lifetime Substance Severity\a
3.0
2.5
Times/Days
2.0
Behavior problems increase
with substance use severity
1.5
1.0
0.5
0.0
Times fighting
(year)*
Days carrying
Times driving under
weapon (month)*
the influence
(month)*
More than
Marijuana
More
than
Marijuana use
Times fighting at
school (year)*
Alcohol Intoxication
Marijuana
Alcohol
Marijuana
useto the right
Intoxication
\a Each severity
level includes any substance
Source: Wisconsin YRBS
\a Each
lifetime severity level includes any substance to the right
Source: Wisconsin 2005 YRBS
Days carried a gun
(month)*
Days carried
weapon at school
(month)*
Alcohol or Tobacco Use
Alcohol or
NoNo Use
Tobacco Use *p<.05 Use
* p<.05
9
Victimization by Substance Severity in WI\a
Victimization Problems by Lifetime Substance Severity\a
2.5
Times/Days
2.0
Victimization also goes up
with substance use severity
1.5
1.0
0.5
0.0
Times hurt on school property
(year)*
More than
Marijuana
More
than
Times had property stolen at
school (year)*
Marijuana
use
Marijuana
Times threatened at school
(year)*
Alcohol
Intoxication
Alcohol
Marijuana
use to the right Intoxication
\a Each severity
level includes any substance
Source:
Wisconsin
YRBS level includes any substance to the right
Each
lifetime
severity
\a
Source: Wisconsin 2005 YRBS
Days felt unsafe at school
(month)*
Alcohol
or Tobacco
Alcohol
or Use
No No Use
Tobacco Use *p<.05Use
* p<.05
10
Mental Health by Substance Severity in WI\a
Depression-Suicide Problems by Lifetime Substance Severity\a
50%
40%
As does mental health…
Percent
30%
20%
10%
0%
Felt sad or hopeless
(year)*
More than
Marijuana
More
than
Considered suicide
(year)*
Marijuana
use
Marijuana
Made suicide plan
(year)*
Attempted suicide
(year)*
AlcoholAlcohol
Intoxication
Marijuana
use to the right Intoxication
\a Each severity
level includes any substance
Source:
Wisconsin
YRBSlevel includes any substance to the right
Each
lifetime
severity
\a
Source: Wisconsin 2005 YRBS
Injured from suicide
attempt (year)*
Alcohol
or Tobacco
Alcohol
or Use
Tobacco Use
No No Use
Use
*p<.05
* p<.05
11
Other Problems by Substance Severity in WI\a
Other Problems by Lifetime Substance Severity\a
50%
40%
Percent
30%
..and other problems
20%
10%
0%
Uncomfortable touch, picture
at school (year)*
than
More thanMore
Marijuana
Harassed at school (year)*
Marijuana
use
Marijuana
Marijuana
Grades mostly Ds/Fs (year)*
Alcohol Alcohol
Intoxication
use
Intoxication
\a Each severity level includes any substance
to the right
Source:
Wisconsin severity
YRBS
Each lifetime
level includes any substance to the right
\a
Source: Wisconsin 2005 YRBS
Usually do not feel safe at
school (year)*
Alcohol
or Tobacco
Alcohol
or Use
Tobacco Use*p<.05
NoNo Use
Use
* p<.05
12
Count of Problems by Substance Severity in WI\a
Count of Problems by Lifetime Substance Severity\a
25
Number of Problems
20
15
The number of different
types of problems also
up with severity
The relationship
between the number of
problems and substance
use severity is even
greater if we focus on
past month use
20.4
13.3
9.0
10
7.1
9.4
6.7
4.8
3.9
5
2.6
2.6
Lifetime
More
More
thanthan
Marijuana Marijuana MarijuanaAlcohol
use
Alcohol
or
Tobacco
Use
No
Use
Marijuana
use
Intoxication
\a Each severity level includes any substance to the right
\a Each*p<.05
severity level includes any substance to the right
Source: Wisconsin 2005 YRBS
Past Month
Alcohol
or Intoxication
No
Alcohol
Tobacco Use
Use
* p<.05
13
Brain Activity on PET Scan
After Using Cocaine
Rapid rise in brain
activity after taking
cocaine
Actually ends up
lower than they
started
1-2 Min
3-4
5-6
6-7
7-8
8-9
9-10
10-20
20-30
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.
14
Brain Activity on PET Scan
After Using Cocaine
With repeated use,
there is a cumulative
effect of reduced
brain activity which
requires increasingly
more stimulation (i.e.,
tolerance)
Normal
Cocaine Abuser (10 days)
Even after 100 days
of abstinence
activity is still low
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.
15
Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine
16
Adolescent Brain
Development Occurs from the
Inside to Out and
Front
Photo courtesy offrom
the NIDABack
Web site.to
From
A
Slide Teaching Packet: The Brain and the
Actions of Cocaine, Opiates, and Marijuana.
pain
17
Substance Use Careers Last for Decades
1.0
.9
Median of 27
years from
first use to 1+
years
abstinence
.8
Cumulative Survival
.7
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
30
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
18
Substance Use Careers are
Longer the Younger the Age of First Use
1.0
.9
Age of
1st Use
Groups
.8
Cumulative Survival
.7
.6
.5
under 15*
.4
15-20*
.3
.2
21+
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
* p<.05
(different
from 21+)
19
Substance Use Careers are
Shorter the Sooner People Get to Treatment
1.0
.9
Year to
1st Tx
Groups
.8
Cumulative Survival
.7
20+
.6
.5
.4
.3
.2
10-19*
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
0-9*
* p<.05
(different
from 20+)20
Treatment Careers Last for Years
1.0
.9
.8
Median of 3
to 4 episodes
of treatment
over 9 years
Cumulative Survival
.7
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
Years from first Tx to 1+ years abstinence
Source: Dennis et al., 2005
21
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
22
110,000
69% increase from
95,017 in 1992
to 160,750 in 2002
50,000
136,660
15% drop off from
160,750 in 2002 to
136,660 in 2006
90,000
70,000
142,646
157,036
158,752
160,750
140,542
137,596
139,129
131,194
129,859
122,910
130,000
95,271
150,000
109,123
170,000
95,017
Number of Admissions Age 12-17 .
190,000
148,772
Trends in Adolescent (Age 12-17) Treatment
Admissions in the U.S.
30,000
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
10,000
Year of Admission
Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm
23
25,559
22,818
20,506
20,154
20,354
16,840
17,322
13,491
15,000
11,004
20,000
14,606
25,000
15,558
26+
18-25
12-17
Total
16,472
30,000
17,596
Has led to growing
admissions in young
and older adults
23,845
Change in WI Public Treatment Admissions:
Age at Admission from 1995 to 2005
30,000
25,000
20,000
15,000
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
-
1995
5,000
1994
5,000
1993
10,000
1992
10,000
Little
Change in
-Adolescent
Admissions
24
Variation by State in the Percentage of Adolescent
Residential Treatment: 1995 to 2005
New Hampshire
Washington
Montana
North
Dakota
Vermont
Maine
Minnesota
Oregon
Massachusetts
South
Dakota
Idaho
Wisconsin
New York
Nebraska
Nevada
Pennsylvania
Iowa
Illinois
Utah
Colorado
California
Indiana
Ohio
Delaware
Virginia
Missouri
Kentucky
Tennessee
Oklahoma
New Mexico
Arkansas
Alabama
Texas
Maryland
District Of Columbia
South Carolina
Mississippi
Alaska
Connecticut
New Jersey
W. Virginia
Kansas
North Carolina
Arizona
Rhode Island
Michigan
Wyoming
% Residential
Georgia
1.6 to 5.9%
Louisiana
Florida
6.0 to 10.5%
10.6 to 18.7%
18.8 to 29.9%
30.0 to 52.3%
Hawaii
Wisconsin significantly
lower than the 16%
11 year average for U.S.
Puerto Rico
10/07
25
Median Length of Stay is only 50 days
Level of Care
Median Length of Stay
Total
(61,153 discharges)
50 days
LTR
(5,476 discharges)
49 days
STR
(5,152 discharges)
21 days
Detox
(3,185 discharges)
3 days
IOP
(10,292 discharges)
Less than
25% stay the
90 days or
longer time
recommended
by NIDA
Researchers
46 days
Outpatient
(37,048 discharges)
59 days
0
30
60
90
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 .
26
53% Have Unfavorable Discharges
Despite being widely
recommended, only
10% step down after
intensive treatment
Total
(61,153 discharges)
LTR
(5,476 discharges)
STR
(5,152 discharges)
Detox
(3,185 discharges)
IOP
(10,292 discharges)
Outpatient
(37,048 discharges)
0%
Completed
20%
Transferred
40%
60%
ASA/ Drop out
80%
100%
AD/Terminated
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 .
27
Key Problems




Lack of standardized assessment for substance
use disorders, mental health disorders,
crime/violence, HIV risk and child maltreatment
No or inconsistent use of placement criteria knowing nothing about the person other than
what door they walked through we can correctly
predict 75% (kappa=.51) of the adolescent level of
care placements (including ASAM systems)
Virtually no link to actual data on the expected
outcomes by level of care to inform decision
making related to placement
The lack of the full continuum of care to refer
people due to availability or finance
28
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
29
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
30
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
31
Impact of the numbers of Favorable
features on Recidivism (509 JJ studies)
Average
Practice
Source: Adapted from Lipsey, 1997, 2005
32
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
NOTE: There is generally little or no differences in mean
effect size between these brand names
Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004
33
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
34
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)
35
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
36
Implementation is Essential
(Reduction in Recidivism from .50 Control Group Rate)
The best is to
have a strong
program
implemented
well
Thus one should optimally pick the
strongest intervention that one can
implement well
Source: Adapted from Lipsey, 1997, 2005
The effect of a well
implemented weak program is
as big as a strong program
implemented poorly
37
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
38
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
39
GAIN Clinical Collaborators
Adolescent and Adult Treatment Program
New Hampshire
Washington
Montana
North
Dakota
Oregon
Vermont
Minnesota
South
Dakota
Idaho
Massachusetts
Wisconsin
New York
Michigan
Wyoming
Nebraska
Nevada
Pennsylvania
Iowa
Illinois Indiana
Ohio
Utah
Colorado
California
Maine
W. Virginia
Kansas
Delaware
Virginia
Missouri
Kentucky
North Carolina
Tennessee
Oklahoma
Arizona
New Mexico
Arkansas
Mississippi
Texas
Maryland
District Of Columbia
South Carolina
Number of GAIN Sites
Georgia
Alabama
0
1 to 10
11 to 25
Louisiana
Alaska
Florida
Hawaii
Rhode Island
Connecticut
New Jersey
26 to 130
GAIN State System
GAIN-SS State or
County System
Puerto Rico
Virgin Islands
10/07
40
CSAT GAIN Data (n=15,254)
Female
27%
CSAT data
dominated by
Male,
Caucasians,
age 15 to 17
16%
African American
42%
Caucasian
32%
Mixed/Other
28%
Hispanic*
19%
12 to 14 years old
79%
15 to 17 years old
71%
Outpatient
9%
Intensive Outpatient
17%
Long Term Residential
CSAT residential more
likely to be over 30 days
3%
Short Term Residential
0%
20%
CSAT data
dominated by
Outpatient
40%
60%
80%
100%
*Any Hispanic ethnicity separate from race group.
Sources: CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).
41
100%
90%
80%
83%
Past Year Substance Diagnosis
50%
Any Past Year Dependence
29%
Any withdrawal symptoms in the past week
Severe withdrawal (11+ symptoms) in past week
70%
60%
50%
40%
30%
20%
10%
0%
Substance Use Problems
7%
94%
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)
34%
29%
26%
42
Past Year Substance Severity by Level of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
72%
75%
LTR
MTR
86%
Use
Abuse
Dependence
57%
38%
10%
0%
OP
IOP
STR
Note: OP=Outpatient, IOP=Intensive Outpatient; LTR= Long Term Residential (90+ days); MTR= Moderate
Term Residential (30-90 days); STR=Short Term Residential (0-30 days)
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
43
Past Year Substance Severity by Gender
100%
90%
80%
70%
60%
Use
Abuse
Dependence
50%
40%
30%
20%
46%
54%
10%
0%
Male
Source: CSAT 2007 AT Outcome Data Set (n=15,254)
Female
44
100%
90%
80%
70%
60%
64%
Sexually active
33%
Sex Under the Influence of AOD
29%
Multiple Sex partners
25%
Any Unprotected Sex
Victimized Physically, Sexually, or
Emotionally
Any Needle use
50%
40%
30%
20%
10%
0%
Past 90 day HIV Risk Behaviors
20%
2%
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
45
Sexual Partners by Level of Care
100%
90%
80%
70%
60%
No Sexual
Partners
50%
40%
30%
52%
20%
10%
27%
33%
39%
38%
LTR
MTR
Multiple
Sexual
Partners
0%
OP
IOP
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
One
Sexual
Partner
STR
46
Sexual Partners by Gender
100%
90%
80%
70%
60%
No Sexual
Partners
50%
40%
One
Sexual
Partner
30%
20%
32%
10%
23%
0%
Male
Source: CSAT 2007 AT Outcome Data Set (n=15,254)
Multiple
Sexual
Partners
Female
47
100%
42%
Attention Deficit/Hyperactivity Disorder
35%
Major Depressive Disorder
24%
Traumatic Stress Disorder
14%
63%
Ever Physical, Sexual or Emotional Victimization
45%
High severity victimization (GVS>3)
31%
Ever Homeless or Runaway
22%
Any homicidal/suicidal thoughts past year
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
90%
50%
Conduct Disorder
Any Self Mutilation
80%
66%
Any Co-occurring Psychiatric
General Anxiety Disorder
70%
60%
50%
40%
30%
20%
10%
0%
Co-Occurring Psychiatric Problems
9%
48
Co-Occurring Psychiatric Diagnoses by Level of Care
100%
90%
80%
70%
60%
50%
40%
68%
30%
54%
10%
52%
42%
20%
None
One
29%
Multiple
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
49
Severity of Victimization by Level of Care
100%
90%
80%
70%
60%
50%
40%
64%
30%
20%
53%
59%
70%
Low
38%
Moderate
10%
High
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
50
Co-Occurring Psychiatric Diagnoses by Gender
100%
90%
80%
70%
60%
50%
40%
None
30%
52%
20%
10%
One
29%
Multiple
0%
Male
Source: CSAT 2007 AT Outcome Data Set (n=15,254)
Female
51
Severity of Victimization by Gender
100%
90%
80%
70%
60%
50%
40%
30%
20%
55%
Low
41%
Moderate
10%
High
0%
Male
Source: CSAT 2007 AT Outcome Data Set (n=15,254)
Female
52
68%
Physical Violence
63%
Any Illegal Activity
48%
Any Property Crimes
Any Interpersonal/ Violent Crime
45%
43%
85%
Lifetime Juvenile Justice Involvement
71%
Current Juvenile Justice involvement
1+/90 days In Controlled Environment
100%
80%
Any violence or illegal activity
Other Drug Related Crimes*
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Past Year Violence & Crime
39%
*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
53
Type of Crime by Level of Care
100%
90%
80%
70%
60%
50%
40%
20%
67%
64%
30%
54%
53%
Drug Use
only
Other
Crime
36%
10%
Violent
Crime
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
54
Type of Crime by Gender
100%
90%
80%
70%
60%
50%
40%
Drug Use
only
30%
20%
46%
35%
10%
Other
Crime
Violent
Crime
0%
Male
Source: CSAT 2007 AT Outcome Data Set (n=15,254)
Female
55
Multiple Problems* are the Norm
100%
90%
None
One
Most
acknowledge
1+ problems
80%
70%
60%
Two
Three
Four
50%
40%
30%
20%
Few present with just
one problem (the
focus of traditional
research)
In fact, 45%present
acknowledging 5+
major problems
Five to
Twelve
10%
0%
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
56
Number of Problems by Level of Care
100%
90%
80%
70%
60%
50%
40%
67%
30%
50%
20%
78%
0 to 1
55%
2 to 4
39%
10%
5 or more
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
57
Number of Problems by Level of Care
100%
90%
80%
70%
60%
50%
40%
0 to 1
30%
20%
55%
2 to 4
41%
10%
5 or more
0%
Male
Source: CSAT 2007 AT Outcome Data Set (n=15,254)
Female
58
No. of Problems* by Severity of Victimization
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None
One
Two
Three
Four
Five+
70%
45%
15%
Low
(OR 1.0)
Mod.
(OR=4.8)
High
(OR=13.8)
Severity of Victimization
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Those with
high lifetime
levels of
victimization
have 117 times
higher odds of
having 5+
major
problems*
59
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
60
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
61
Variance Explained in 10 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%
62
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
63
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
64
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
65
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
66
NOMS Outcome: Treatment Received by Gender
0%
20%
40%
60%
80%
100%
Initiation with 14 days
Evidenced Based Practice
Engagement for at least 6 weeks
Any Continuing Care (91-180 days)
Substance Use-Abstinent/Reduced 50% at
3 Months
12 Month Cost Within Bands for Initial
Type of Treatment
Source: CSAT 2007 AT Outcome Data Set (n=11,294)
Male
Female
67
NOMS Outcome: 50% Reduction or None
0%
20%
40%
60%
80%
100%
Substance Use
Substance Problems
Health Problems
Emotional Problems
Behavioral Problems
Illegal Acitvity
Family Problems
Social Risk
Recovery Environment Risk
Trouble at School or Work
Nights in Psychiatric Inpatient Unit
Costs to Society
Source: CSAT 2007 AT Outcome Data Set (n=11,294)
Male
Female
68
NOMS Outcome at 12 months post-intake
0%
20%
40%
60%
80%
100%
Abstinent (Past Month)
Early Remission (Past Month)
No major health problems
No major mental health problems
No Illegal Activity
Free of the Justice System
Living in the Community
No Family/home problems
In School or Work
Social Support
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
Male
Female
69
Change in Days Abstinent (while in
community) by Level of Care and Gender
90
80
Days of Abstinence
70
60
50
40
30
Female - OP (d=0.43)
20
Males - OP (d=0.33)
Female - Resid (d=0.82)
10
Males -Res (d=0.74)
0
Intake
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
Last Followup
70
MALES: Change in Adjusted Days
Abstinent by type of Outpatient Approach
90
MST (d=0.87)
Motivational Interviewing (d=0.79)
80
ACRA/ACC (d=0.53)
Days of abstinence
70
FSN (d=0.48)
Other (d=0.44)
60
METCBT5 (d=0.33)
Total (d=0.33)
50
Other CBT (d=0.32)
40
Seven Challenges (d=0.27)
METCBT12 (d=0.2)
30
EMPACT (d=0.18)
20
CHS OP (d=0.15)
MDFT (d=0.07)
10
Manualized Practice Tx (d=0.03)
METCBT7 (d=-0.03)
0
Intake
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
Last Followup
71
FEMALES: Change in Adjusted Days
Abstinent by type of Outpatient Approach
90
Manualized Practice Tx (d=0.94)
Motivational Interviewing (d=0.87)
80
MST (d=0.86)
Days of abstinence
70
Other (d=0.51)
CHS OP (d=0.48)
60
50
METCBT12 (d=0.48)
=
Seven Challenges (d=0.44)
Total (d=0.42)
40
FSN (d=0.41)
Other CBT (d=0.41)
30
METCBT5 (d=0.4)
METCBT7 (d=0.38)
20
MDFT (d=0.36)
10
0
ACRA/ACC (d=0.35)
EMPACT (d=0.02)
Intake
Last Follow-up
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
72
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
73
Replication and Site Effects



Treatment can vary by
implementation within
site/clinic
We want to compare the
range of implementation
in practice with the
clinical trials
In order to compare sites,
we will at both the central
tendency (median) and
distribution using a Tukey
Box Plot like the one
shown here.
3.00
Median
2.50
2.00
Middle 50%
1.50
1.00
0.50
“Range”
0.00
-0.50
-1.00
-1.50
-2.00
Criteria
74
Range of Effect Sizes (d) for Change in Days
of Abstinence (intake to 12 months) by Site
1.40
Cohen’s d
1.20
6 programs
completely
above CYT
EAT Programs did
Better than CYT on
average
1.40
1.20
1.00
1.00
0.80
0.80
0.60
0.60
0.40
0.40
0.20
0.20
75% above CYT
median
0.00
4 CYT Sites (f=0.39)
(median within site d=0.29)
Source: Dennis, Ives, & Muck, 2008
0.00
36 EAT Sites (f=0.21)
(median within site d=0.49)
75
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
77
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)
78
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.
79
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
80
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
81
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
82
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.
83
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

Evidenced based interventions and their outcomes
can be replicated in practice

Continuing care and is a key determinant of long
term outcomes
84