Transcript 5 - Chestnut Health Systems

Advances in
Adolescent Substance Abuse
Treatment and Research
Michael Dennis, Ph.D.
Chestnut Health Systems,
Bloomington, IL
Part of the continuing education workshop, “Advancing the Field of Adolescent Substance
Abuse Treatment”, Hamden, CT, April 22, 2005. Sponsored by the Department of Children and
Families Substance Abuse Division. 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 and 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) 8276026, fax: (309) 829-4661, e-Mail: [email protected]
Goals of this Presentation

Examine the prevalence, course, and consequences of
adolescent substance use and co-occurring disorders

Examine the rates of use, substance use disorders (SUD)
and unmet treatment needs in the US and CT

Summarize major trends in the adolescent treatment
system

Review the current knowledge base on treatment
effectiveness

Examine how characteristics vary by intensity of
juvenile justice system involvement

Examine the results of recent major studies
Relationship between Past Month
Substance Use and Age
Source: Dennis (2002) and 1998 NHSDA
Age of First Use Predicts Dependence
an Average of 22 years Later
100
Under Age 15
% with 1+ Past Year Symptoms
90
Aged 15-17
80
Aged 18 or older
71
70
63
62
60
51
50
40
45
39 37
30
30
48
41
34
23
20
10
0
Tobacco:
Alcohol:
Pop.=151,442,082
Tobacco,
OR=1.3*, Pop.=176,188,916
Alcohol, OR=1.9*,
Pop.=151,442,082
Pop.=176,188,916
OR=1.49*
OR=2.74*
Source:
Marijuana:
Other Drugs:
Pop.=71,704,012
Marijuana, OR=1.5*, Pop.=38,997,916
Other, OR=1.5*,
Pop.=71,704,012 OR=2.65*
Pop.=38,997,916
OR=2.45*
* p<.05
Dennis, Babor, Roebuck & Donaldson (2002) and 1998 NHSDA
The Growing Incidence of Adolescent
Marijuana Use: 1965-2002
Adolescent
Initiation Rising
Adult Initiation
Relatively Stable
Source: OAS (2004). Results from the 2003 National Survey on Drug Use and Health: National Findings.
Rockville, MD: SAMHSA. http://oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.pdf
Source: Office of Applied Studies. (2000). 1998 NHSDA
Risk & Availability
Marijuana Use
Importance of Perceived Risk
Actual Marijuana Risk




From 1980 to 1997 the potency of marijuana in
federal drug seizures increased three fold.
The combination of alcohol and marijuana has
become very common and appears to be synergistic
and leads to much higher rates of problems than
would be expected from either alone.
Combined marijuana and alcohol users are 4 to 47
times more likely than non-users to have a wide
range of dependence, behavioral, school, health and
legal problems.
Marijuana and alcohol are the leading substances
mentioned in arrests, emergency room admissions,
autopsies, and treatment admissions.
Substance Use in the Community
No Alcohol/
Marijuana
use 60%
Yearly
Alcohol
Use 15%
Monthly
Alcohol
Use 7%
Weekly
Alcohol
Use 2%
Marijuana
Use Only
1%
Yearly
Marijuana &
Alcohol Use
6%
Monthly
Marijuana &
Alcohol Use
4%
Weekly
Marijuana &
Alcohol Use
4%
Source: Dennis and McGeary (1999) and 1997 NHSDA
Consequences of Substance Use
100
77
80
69
67
57
60
51
47
44
40
47
29
13
20
0
11
0 1
25
15
33
28
17
23
17
11
6
1
0
% 1+
% 1+
% Clinical
Symptom of Symptom of Behavior
Alcohol
Cannabis
Problems
Disorder
Disorder
% Physical
Fight
% Out of
School
% with 1+
ER in the
past year
No Past Year Alcohol or Marijuana Use
Weekly Alcohol Use
Weekly Marijuana Use (with Alcohol Use)
Source: Dennis, Godley and Titus (1999) and 1997 NHSDA
% Any
Illegal
Activity
% 1+
Arrests
National=8.92%
CT=9.36%
Source: D. Wright (2004). State Estimates of Substance Use
from the 2002 National Survey on Drug Use and
Health, Rockville, MD: OAS, SAMHSA
http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
Adolescents with Past Year Alcohol or Other
Drug (AOD) Abuse or Dependence
National=5.55%
CT=5.22%
Source: D. Wright (2004). State Estimates of Substance Use
from the 2002 National Survey on Drug Use and
Health, Rockville, MD: OAS, SAMHSA
http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
Adolescents Needing But Not Receiving
Treatment for Alcohol Use
National=5.14%
CT=5.50%
Source: D. Wright (2004). State Estimates of Substance Use
from the 2002 National Survey on Drug Use and
Health, Rockville, MD: OAS, SAMHSA
http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
Adolescents Needing But Not Receiving
Treatment for Illicit Drug Use
10
14
10
100
Binge Alcohol Use
6
69
45
Age 18-25
90
Any Alcohol Use
17
Age 12-17
80
70
60
50
40
30
20
0
10
Rates of Use in CT by Age
Any Past Month
Illicit Drug Use
23
20
Any Past Month
Marijuana Use
21
Any Past Month
Illicit Beside
Marijuana
9
63
Age 26+
6
4
3
Source: D. Wright (2004). State Estimates of Substance Use from the 2002 National Survey on Drug
Use and Health, Rockville, MD: OAS, SAMHSA.
http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
Rates of SUD and Unmet Tx Need in CT by Ag
9
9
Age
12-17
5
6
18
5
6
2
35
22
Age
18-25
18
8
6
5
30
Either
Alcohol
Drug
23
9
25
20
15
10
0
5
Unmet Treatment Need
35
30
25
20
15
10
5
0
Abuse or Dependence
Age
26+
6
5
1
Source: D. Wright (2004). State Estimates of Substance Use from the 2002 National Survey on Drug Use and
Health, Rockville, MD: OAS, SAMHSA. http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
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
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
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+)
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+)
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
Years from first Tx to 1+ years abstinence
Source: Dennis et al., 2005
25
Adolescent Treatment Admissions have
increased by 50% over the past decade
Number of Unique Individuals .
180,000
160,000
140,000
120,000
100,000
50% higher
than in 1992
80,000
60,000
40,000
20,000
0
1992 1993 1994
1995 1996 1997 1998 1999 2000
2001 2002 2003
Year of Admission
Source: Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS)
http://www.samhsa.gov/oas/dasis.htm
Change in Primary Substance
+317% increase
in marijuana
-50% decrease
in alcohol
+375%
increase in
stimulants
-21%
decrease
in cocaine
Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD:
SAMHSA. http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf
+144%
increase
in opiates
Change in Referral Sources
JJ referrals have
doubled and are
driving growth
Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA
http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf
Primary Substance by Referral Source
More recent
marijuana
referrals driven
more by JJ
Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA
http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf
Severity Varies by Level of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Severity goes up with
level of care
Weekly use at
intake
* Weekly use
is the Norm
* 1 in 5 report with
no past month use
Source:
Dependence
STR clients get there
younger and sooner
First used
Prior Treatment
under age 15
Outpatient (n=24704)
Intensive Outpatient (n=4024)
Detoxification or Hospital (n=2062)
Long Term Residential (n=3124)
Short Term Residential (n=2046)
Dennis, Dawud-Noursi, Muck & McDermeit, 2002
and 1998 Treatment Episode Data Set (TEDS)
Key Problems in the U.S. System

Less than 1/10th of adolescents with substance
dependence problems receive treatment

Less than 50% stay 6 weeks

Less than 75% stay the 3 months recommended
by NIDA

Under 25% in Residential Treatment successfully
step down to outpatient care

Little is known about the rate of initiation after
detention
Source: Dennis, Dawud-Noursi, Muck, & McDermeit (Ives), 2002; Godley et al., 2002; Hser et al., 2001;
OAS, 2000
Outpatient Level of Care Placement (n=655)
III Waiting for Residential/Inpatient Services (1%)
No Treatment Needed (2%)
II. Intensive
Outpatient/ Partial
Hospitalization
(10%)
0.5 Early Intervention
24%
I. Outpatient Service (63% )
Source: The Connecticut Department of Children and Families Substance Abuse
Division, FY2004.
Presenting Problems Reported to the State
(primary, secondary, or tertiary)
0%
10%
20%
30%
40%
80%
90%
8%
Other SUD
External
Health
70%
24%
Alcohol
Internal
(Homicide/suicide/
Trauma Related)
Psychosocial Stress
60%
76%
Cannabis
(Crime/Violence)
50%
34%
1%
9%
3%
13%
0%
Source: The Connecticut Department of Children and Families Substance Abuse
Division, FY2004.
Percent Discharged
Length of Stay (in days) for Adolescent
Outpatient Treatment in CT
100
90
80
70
60
50
40
30
20
10
0
Better than
National
Average
Still, 50% are
gone in less than
90 days
0
90
180
Length of Stay (Days)
270
360
Source: The Connecticut Department of Children and Families Substance Abuse
Division, FY2004.
Studies by Date of First Publication
Total
14
Epidemiology
4
Clinical
26
5
9
8
Pharmacology
3
0
24
16
5
5
8
10
15
1970-97 Publications
20
25
40
The results of
more Clinical
Trials were
presented last
month at JMATE
than had been
published
through 2002!
30
35
40
1998-2002 Publications
From 1998 to 2002 the number of adolescent treatment studies doubled and
has doubled again in the past 2 years – with twice this many published in the
past 2 years and over 100 adolescent treatment studies currently in the field
Source: Dennis &, White (2003) at www.drugstrategies.org
Impact on Substance Use and Problems

Reductions associated with a wide range of 12-step
treatment (e.g., CD, Hazelden), individual and group
behavior therapies (e.g., ACRA, AGT, BTOS, CBT, MET,
RP), family therapy (BSFT, CFT, FDE, FFT, FSN, FST,
MDFT, MST, PBFT, TIPS), adolescent treatment as usual
(outpatient, short term, long term/therapeutic communities)
and continuing care (Step down, ACC)

No or minimal change associated with passive referrals,
Educational units alone, probation services as usual, and
early unstandardized outpatient services as usual

Deterioration associated with treatment of adolescents in
adult units, with adult models/materials
Source: Bukstein & Kithas, 2002; Dennis & White (2003), & Lewinsohn et al. 1993; PNLDP, 2003
Effectiveness was also associated with
therapies that technologically were:

manual-guided

had developmentally appropriate materials

involved more quality assurance and clinical
supervision to improve adherence/ implementation

achieved early therapeutic alliance and positive
outcomes

successful in engaging adolescents in aftercare, support
groups, positive peer reference groups, more supportive
recovery environments
Key Points that Have Been Contentious






As other therapies have improved, there is no longer the clear
advantage of family therapy found in early literature reviews
While there have been concerns about the potential iatrogenic
effects of group therapy, the rates do not appear to be appreciably
different from individual or family therapy if it is done well
(important since group tx typically costs less)
Effectiveness was not consistently associated with the amount of
therapy over a short period of time (6-12 weeks) but was related
to longer term continuing care
Over time, adolescents regularly cycle between use, treatment,
incarceration and recovery
Treatment primarily impacts the short term movement from use
to non use in the community
The long term effectiveness of therapy was dependent on
changes in the long term recovery environment and social risk
Other Important Lessons






Assessment needs to be very concrete
Multiple co-occurring problems are the norm in clinical
samples of SUD adolescents (60-80% external disorders,
25-60% mood disorders, 16-45% anxiety disorders, 70-90%
3 or more diagnoses)
Adolescents are involved in multiple systems competing to
control their behavior (e.g, family, peers, school, work,
criminal justice, and controlled environments)
Relapse is common in the first 3-12 months
Improvements generally come during active treatment and
are sustained for 12 or more months
Family therapies are associated with more change post
active treatment and less relapse
Limitations of the Early Literature








Small sample sizes (most under 50)
High rates (30-50%) of refusals by eligible people
Unstandardized measures, no measures of abuse or
dependence, no measures of co-morbidity, crime or
violence (just arrest)
Unstandardized and minimally-supervised therapies
(making replication very difficult)
Minimal information on services received
High rates (20-50%) of treatment dropout
High rates of attrition from follow-up (25-54%) leading
to potentially large (unknown) bias
No controlled trials of medication for treating
withdrawal, substitution therapy, blocking therapy,
aversive therapy or management of cravings (though
Buprenorphine studies are now under way)
Studies are Improving!

New studies are likely to have higher rates of
participation (70-90%), treatment completion (70-85%),
and successful follow-up (85-95%)

They are more likely to involve standardized
assessments, manual-guided therapy, and better quality
assurance/clinical supervision

They have experimental design, multiple time points of
assessment and follow-up lasting 1 or more years

They include economic analysis of their costs, costeffectiveness and benefit cost

Many have agreed to pool their data to facilitate further
comparisons and secondary analysis
Studies with Publications Currently Coming Out














1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of
Adolescents (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 36 Effective Adolescent Treatment (EAT)
2004-2007 NIAAA/CSAT’s study of diffusion of innovation
Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN)
Adolescent and Adult Treatment Program
GAIN Clinical Collaborators
CSAT
Co-occurring Disorder (CD) Studies
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Young Offender Re-Entry Program (YORP)
Targeted Capacity Expansion (TCE) grants
Other Collaborators
RWJF Reclaiming Futures Program
Other RWJF Grantees
NIAAA/NIDA Other Grantees
Other Grants/Contracts
State, county, or agency systems
Other states, counties, or agencies
proposing or considering it
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.
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
Length of Stay Varies by Level of Care
100%
L o n g T erm R esid en tial (m ed ian = 1 5 5 d ay s; n = 2 2 2 )
P ercen t S till in T reatm en t
S h o rt T erm R esid en tial (m ed ian = 4 0 d ay s; n = 5 8 9 )
O u tp atien t (m ed ian = 2 1 3 d ay s; n = 4 7 )
50%
L ength of S tay
Source:
Adolescent Treatment Model (ATM) Data
390
360
330
300
270
240
210
180
150
120
90
60
30
0
0%
Adolescents often go through multiple levels of care
100%
In d ex E p iso d e o f C are (m ed ian = 5 2 d ays; n = 1 3 8 0 )
P e rc e n t S till in T re a tm e n t
S ystem E p iso d e o f C are (m ed ian = 7 3 d ays; n = 1 3 8 0 )
Length of Stay Across Episodes of
care is about 50% longer
50%
L en g th o f S tay
Source:
Adolescent Treatment Model (ATM) Data
390
360
330
300
270
240
210
180
150
120
90
60
30
0
0%
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
Years of Use
Source: Adolescent Treatment Model (ATM) data
Patterns of Weekly (13+/90) Use
100
83
80
61
60
72
71
57
56
44
40
29
43
41
29
21
20
14
20
4 1
7
7
4
17
9
0
OP/IOP (n=560)
LTR (n=390)
Weekly use of anything
Weekly Alcohol Use
Weekly Heroin/Opioid Use
13+ Days in Controlled Environment
Source: Adolescent Treatment Model (ATM) data
STR (n=594)
Weekly Marijuana Use
Weekly Crack/Cocaine Use
Weekly Other Drug Use
Substance Use Severity
Source: Adolescent Treatment Model (ATM) data
Change in Substance Frequency Index
by Level of Care\a
\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.
Change in Substance Problem Index
by Level of Care\a
\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.
Percent in Recovery (no past month use or
problems while living in the community)
\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.
Multiple Co-occurring Problems Were the
Norm and Increased with Level of Care
100
88
80
80
60
78
68
70
65
56
44
52
47
43
35
40
21
52
25
44
36
21
20
0
Conduct
Disorder
Outpatient
ADHD
Major
Depressive
Disorder
Generalized
Anxiety
Disorder
Long Term Residential
Traumatic
Stress
Disorder
Any CoOccurring
Disorder
Short Term Residential
Source: CSAT’s Cannabis Youth Treatment (CYT) and Adolescent Treatment Model (ATM),
Change in Emotional Problem Index
by Level of Care\a
\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.
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
High Rates of Victimization are the Norm
Source: Adolescent Treatment Model (ATM) data
Victimization Is Related to Severity
0.4
0.3
Effect Size (f)
0.2
0.1
Pathology
goes up
with High
Victim.
0
-0.1
-0.2
-0.3
Use goes
up with
-0.4
Moderate
Victim.
Substance
Substance
General Mental
Frequency
Problem Index Distress Index
Index
(SPI16; f=.21) (GMDI; f=.32)
(SFI6P; f=.13)
Low (n=80)
Source: Titus, Dennis, et al., 2003
Moderate (31)
Traumatic
Stress Index
(TSI; f=.25)
General
Conflict Tactic
Index
(GCTI; f=.20)
High (n=102)
Victimization Also Interacts with Level of
Care to Predict SA Outcomes
Outpatient
Marijuana Use (Days of 90)
40
Residential
Traumatized groups
35have higher severity
30
25
20
15
10
Acute trauma group
does not respond to OP
5
0
Intake
OP -Acute
Source: Funk, et al., 2003
6 Months
OP - Low/Cl.
Both groups respond to
residential treatment
Intake
Resid-Acute
6 Months
Resid - Low/Cl.
Broad Range of Past Year Illegal Activity
100
95
93
86
90
80
93
80
74
81
78
69
71
OP/IOP (n=560)
LTR (n=390)
65
70
85
82
81
68
60
50
40
30
20
10
0
Any illegal activity
Drug related crimes
Property crimes
Acts of physical violence
Source: Adolescent Treatment Model (ATM) data
STR (n=594)
Interpersonal crimes
Secondary Analysis by
Intensity of Juvenile Justice System Involvement
Low
Hi
Severity
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Detention 14+ days (n=433)
Probation/parole and urine monitoring 14+ days (n=472)
Other detention, parole, or probation (n=374)
Other current arrest or JJ status (n=303)
Past arrest or JJ status (n=170)
Past year illegal activity (n=298)
Source: CYT & ATM Data
But the Same Issues Exist Across the Continuum
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Dependence
Any
Co-occurring
Detention 14+ days (n=433)
Other detention, parole, or probation (n=374)
Past arrest or JJ status (n=170)
Source: CYT & ATM Data
High levels of
Victimization
High Crime/
Violence
Probation/parole and urine monitoring 14+ days (n=472)
Other current arrest or JJ status (n=303)
Past year illegal activity (n=298)
Intensity by Other Common Problems
100%
90%
Focus of JJ
Detention
80%
70%
60%
50%
40%
30%
20%
10%
0%
Any
High levels of
Victimization Victimization
Any
Crime
Detention 14+ days (n=433)
Other detention, parole, or probation (n=374)
Past arrest or JJ status (n=170)
Source: CYT & ATM Data
High Crime/
Violence
Homeless or
Runaway
High Health
Problems
Probation/parole and urine monitoring 14+ days (n=472)
Other current arrest or JJ status (n=303)
Past year illegal activity (n=298)
GAIN’s Crime and Violence Scale at Intake
can predict 30 Months Recidivism
100%
90%
80%
70%
No crime
Incarcerated
Substance Use only
Non-violent crime
Violent crime
60%
50%
40%
X2(8)=18.36, p<.05
30%
20%
10%
0%
Low (n=150)
Source: White et al (2003), PETSA
Moderate (n=158)
High (n=216)
Odds of
committing
violent
crime 4.5
times higher
Crime/Violence and Substance Problems
Interact to Predict Recidivism
The
probability of
committing
another crime
goes up with
the CVS score
80%
60%
40%
20%
0%
Crime and
Violence
Scale
Source: Dennis et al 2004
Knowing both is the
best predictor
Probability of
12 month recidivism
100%
The probability
of committing
another crime
goes up with the
SPS score
Substance Problem Scale
(Abuse/Dependence symptoms)
Change in Illegal Activity Index
by Level of Care\a
\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.
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
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)
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
23
FSN adds multi
family group,
family
home visits
20
and more case
MET/CBT12
adds 7 management
more
ACRA and MDFT
both rely on
individual, family and
case
management
And
MDFT
instead
using
moreof group
family therapy
With ACRA
using more
11
individual
therapy
Hours
15 of
sessions
group
10
10
5
Case
M anagement
Family
Counseling
14
Collateral only
Days
25
5
M ulti-Family
group
M ulti-P articipant
Group
5
P articipant only
0
M E T/
M E T/
M E T/
M E T/
CBT5
CBT12
CBT12 +
CBT5
ACRA
M DFT
FSN
In crem en tal Arm
Source: Dennis et al, 2004
Altern ative 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








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)
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, 2004
Adolescent Cannabis Users in CYT were
as or More Severe Than Those in TEDS*
100%
% of Admissions
.
85%
78%
80%
71%
60%
47%
46%
40%
26%
26%
26%
20%
0%
F irst used
D ependence
W eekly or
P rior
under age
m ore use at
T reatm ent
15
intake
CY T O utpatient(n=600)
TE D S O utpatient (n=16,480)
* Adolescents w ith m arijuana problem s adm itted to outpatient treatm ent
Source: Tims et al, 2002
Demographic Characteristics
100%
83%
80%
62%
55%
60%
50%
40%
30%
17%
15%
20%
0%
Female
Male
African
American
Caucasian Under 15
15 to 16
Single
parent
family
Source: Tims et al, 2002
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
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 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
Substance Use Severity was
Related to Other Problems
100%
80%
71%
57%
60%
42%
40%
37%
30%
25%
22%
22%
20%
13%
5%
0%
H e a lth P roble m
A c ute M e nta l
A c ute
A tte ntion
C onduc t
D istre ss*
D istre ss*
T ra um a tic
D e fic it
D isorde r*
D istre ss*
H ype ra c tivity
D isorde r*
* p<.05
P ast Y ear D ep en d en ce (n = 2 7 8 )
Source: Tims et al 2002
O th er (n = 3 2 2 )
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
Source: Dennis et al., 2004
3
6
9
12
% in Recovery at the End of the Quarter
CYT Increased Days Abstinent and Percent
in Recovery (no use or problems while in community)
Similarity of Clinical Outcomes
by Conditions
Total days abstinent .
over 12 months
300
50%
280
40%
260
30%
240
20%
220
10%
200
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
** p<.05, effect size f=0.12
Source: Dennis et al., 2004
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.16
0%
Percent in Recovery .
at Month 12
Trial 2
Trial 1
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
* p<.05 effect size f=0.22
** p<.05, effect size f=0.78
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
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
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:
Source:Dennis
Dennisetetal,
alforthcoming
forthcoming
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)
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
Assertive Continuing Care (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)
Assertive Continuing Care (ACC)
Hypotheses
Assertive
Continuin
g Care
General
Continuin
g Care
Adherence
Early
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.
Sustained
Abstinence
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, forthcoming
UCC
ACC
* p<.05
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ACC Improved Adherence
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
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Source: Godley et al 2002, forthcoming
Marijuana (OR=1.98*)
* p<.05
Early (0-3 mon.) Abstinence Improved
Sustained (4-9 mon.) Abstinence
100%
90%
80%
73%
69%
70%
59%
60%
50%
40%
30%
20%
22%
19%
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, forthcoming
Marijuana (OR=11.15*)
* p<.05
Concluding Comments

We are entering a renaissance of new knowledge in this
area, but are only reaching 1 of 10 in need

Several interventions work, but 2/3 of the adolescents are
still having problems 12 months later

Effectiveness is related to severity, intervention strength,
and adherence/implementation.

We need to move beyond focusing on acute episodes of
care to focus on continuing care and a recovery
management paradigm

It is very difficult to predict exactly who will relapse so it
is essential to conduct aftercare monitoring with all
adolescents

Juvenile justice referrals are a central factor in recent
growth of the adolescent treatment system and the
intensity of JJ involvement is correlated with clinical
severity
Resources

Copy of these slides and handouts
–

Assessment Instruments
–
–
–

–
CSAT CYT, ATM, ACC and other 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
Adolescent Treatment Programs and Studies
–
–
–
–

CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html
NIAAA Assessment Handbook,http://www.niaaa.nih.gov/publications/instable.htm
GAIN Coordinating Center www.chestnut.org/li/gain
Adolescent Treatment Manuals
–

http://www.chestnut.org/LI/Posters/
List of programs by state and summary of pre-2002 studies at
www.drugstrategies.com
Cannabis Youth Treatment (CYT) : www.chestnut.org/li/cyt
Persistent Effects of Treatment Study of Adolescents (PETSA):
www.samhsa.gov/centers/csat/csat.html (then select PETS from program resources)
Adolescent Program Support Site (APSS): www.chestnut.org/li/apss
Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE)
–
–
–
Website at www.chestnut.org/li/apss/sasate with bibliography
E-mail Darren Fulmore <[email protected]> to be added to list server
Next conference is March 21-23, 2005, See website or E-mail Darren for information
about meeting
References
Babor, T. F., Webb, C. P. M., Burleson, J. A., & Kaminer, Y. (2002). Subtypes for classifying adolescents with marijuana use
disorders Construct validity and clinical implications. Addiction, 97(Suppl. 1), S58-S69.
Buchan, B. J., Dennis, M. L., Tims, F. M., & Diamond, G. S. (2002). Cannabis use Consistency and validity of self report, onsite urine testing, and laboratory testing. Addiction, 97(Suppl. 1), S98-S108.
Bukstein, O.G., & Kithas, J. (2002) Pharmacologic treatment of substance abuse disorders. In Rosenberg, D., Davanzo, P.,
Gershon, S. (Eds.), Pharmacotherapy for Child and Adolescent Psychiatric Disorders, Second Edition, Revised and Expanded. NY,
NY: Marcel Dekker, Inc.
Dennis, M.L., (2002). Treatment Research on Adolescents Drug and Alcohol Abuse: Despite Progress, Many Challenges
Remain. Connections, May, 1-2,7, and Data from the OAS 1999 National Household Survey on Drug Abuse
Dennis, M.L. (2004). Traumatic victimization among adolescents in substance abuse treatment: Time to stop ignoring the
elephant in our counseling rooms. Counselor, April, 36-40.
Dennis, M.L., & Adams, L. (2001). Bloomington Junior High School (BJHS) 2000 Youth Survey: Main Findings. Bloomington,
IL: Chestnut Health Systems
Dennis, M. L., Babor, T., Roebuck, M. C., & Donaldson, J. (2002). Changing the focus The case for recognizing and treating
marijuana use disorders. Addiction, 97 (Suppl. 1), S4-S15.
Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003). The need for developing and evaluating adolescent
treatment models. In S.J. Stevens & A.R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary
Models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press and 1998 NHSDA.
Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C.,
Hamilton, N., & Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials.
Journal of Substance Abuse Treatment, 27, 197-213.
Dennis, M. L., Godley, S. and Titus, J. (1999). Co-occurring psychiatric problems among adolescents: Variations by treatment,
level of care and gender. TIE Communiqué (pp. 5-8 and 16). Rockville, MD: Substance Abuse and Mental Health Services
Administration, Center for Substance Abuse Treatment.
Dennis, M. L., Perl, H. I., Huebner, R. B., & McLellan, A. T. (2000). Twenty-five strategies for improving the design,
implementation and analysis of health services research related to alcohol and other drug abuse treatment. Addiction, 95, S281S308.
Dennis, M. L. and McGeary, K. A. (1999). Adolescent alcohol and marijuana treatment: Kids need it now. TIE Communiqué
(pp. 10-12). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse
Treatment.
References - continued
Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F., Webb, C., Kaminer, Y., Babor, T., Roebeck, M.
C., Godley, M. D., Hamilton, N., Liddle, H., Scott, C., & CYT Steering Committee. (2002). The Cannabis Youth Treatment (CYT)
experiment Rationale, study design, and analysis plans. Addiction, 97, 16-34..
Dennis, M. L., Titus, J. C., White, M., Unsicker, J., & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN)
Administration guide for the GAIN and related measures. (Version 5 ed.). Bloomington, IL Chestnut Health Systems. Retrieve from
http//www.chestnut.org/li/gain
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.
Diamond, G., Leckrone, J., & Dennis, M. L. (In press). The Cannabis Youth Treatment study Clinical and empirical
developments. In R. Roffman, & R. Stephens, (Eds.) Cannabis dependence Its nature, consequences, and treatment . Cambridge, UK
Cambridge University Press.
Diamond, G., Panichelli-Mindel, S. M., Shera, D., Dennis, M. L., Tims, F., & Ungemack, J. (in press). Psychiatric syndromes in
adolescents seeking outpatient treatment for marijuana with abuse and dependency in outpatient treatment. Journal of Child and
Adolescent Substance Abuse.
French, M.T., Roebuck, M.C., Dennis, M.L., Diamond, G., Godley, S.H., Tims, F., Webb, C., & Herrell, J.M. (2002). The
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