cannabis youth treatment experiment: 12 and 30 month main findings michael dennis, ph.d. (on behalf...

Cannabis Youth Treatment Experiment: 12 and 30 Month Main Findings

Michael Dennis, Ph.D. (On Behalf of the CYT Steering Committee)Chestnut Health SystemsBloomington, 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.

http://www.chestnut.org/li/posters

mailto:[email protected]

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

Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services

Coordinating Center:Chestnut Health Systems, Bloomington, IL, and Chicago, ILUniversity of Miami, Miami, FLUniversity of Conn. Health Center, Farmington, CT

Sites:Univ. of Conn. Health Center, Farmington, CTOperation PAR, St. Petersburg, FLChestnut Health Systems, Madison County, ILChildren’s Hosp. of Philadelphia, Phil. ,PA

Marijuana

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

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

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 cost-effectiveness 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

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)

Randomly Assigns to:

MET/CBT5Motivational Enhancement Therapy/

Cognitive Behavioral Therapy (5 weeks)



FSN

Family Support Network

Plus MET/CBT12 (12 weeks)

ACRAAdolescent Community

Reinforcement Approach(12 weeks)

MDFTMultidimensional Family Therapy

Experiment 2Experiment 1Incremental Arm Alternative Arm

Two Experiments or Study Arms

Randomly Assigns to:



(12 weeks)

Source: Dennis et al, 2002

Contrast of the Treatment Structures

Individual Adolescent Sessions

CBT Group Sessions

Individual Parent Sessions

Family Sessions/Home Visits

Parent Education Sessions

Total Formal Sessions

Type of ServiceMET/CBT5

MET/CBT12 FSN ACRA MDFT

2

3

5

2

10

12

2

10

4

6

22

10

2

2

14

6

3

6

15

Case management/Other Contacts

As needed

As needed

As needed

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

5

10

5

11

14

23

0

5

10

15

20

25

MET/CBT5

MET/CBT12

MET/CBT12 +

FSN

MET/CBT5

ACRA MDFT

Hou

rs

Day

s

CaseManagement

FamilyCounseling

Collateral only

Multi-Familygroup

Multi-ParticipantGroup

Participant only

Incremental Arm Alternative Arm

Actual Treatment Received by Condition

Source: Dennis et al, under review

MET/CBT12 adds 7 more sessions of

group

FSN adds multi family group,

family home visits and more case management

ACRA and MDFT both rely on

individual, family and case management instead of group

With ACRA using more individual therapy

And MDFT using more

family therapy

$1,559$1,413

$1,984

$3,322

$1,197$1,126

$-

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

MET/C

BT5 (6.8

wee

ks)

MET/C

BT12 (1

3.4 w

eeks

)

FSN (14.2

wee

ks w

/family

)

MET/C

BT5 (6.5

wee

ks)

ACRA (12.8

wee

ks)

MDFT(1

3.2 w

eeks

w/fa

mily)

$1,776

$3,495

NTIES E

st (6

.7 wee

ks)

NTIES E

st.(1

3.1 w

eeks

)

Ave

rage

Cos

t P

er C

lien

t-E

pis

ode

of C

are

|--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----|

Average Episode Cost ($US) of Treatment

Source: French et al., 2002

Less than average

for 6 weeks

Less than average

for 12 weeks

Implementation of Evaluation

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*

85%

46%

26%

78%

26%

47%

26%

71%

0%

20%

40%

60%

80%

100%

First usedunder age

15

Dependence Weekly ormore use at

intake

PriorTreatment

% o

f A

dm

issi

on

s

.

CYT Outpatient(n=600) TEDS Outpatient (n=16,480)* Adolescents with marijuana problems admitted to outpatient treatment

Source: Tims et al, 2002

Demographic Characteristics

62%

15%

55%50%

30%

83%

17%

0%

20%

40%

60%

80%

100%

Female Male AfricanAmerican

Caucasian Under 15 15 to 16 Singleparentfamily


Institutional Involvement

25%

87%

47%

62%

0%

20%

40%

60%

80%

100%

In school Employed Current CJInvolvement

Coming fromControlled

Environment


Patterns of Substance Use

9%17%

71%73%

0%

20%

40%

60%

80%

100%

Weekly Tobacco Use

WeeklyCannabis Use

Weekly AlcoholUse

Significant Timein ControlledEnvironment


Multiple Problems are the NORM

86%

37%

12%

25%

61%

60%

66%

83%

83%

0% 20% 40% 60% 80% 100%

Any Marijuana Use Disorder

Any Alcohol Use Disorder

Other Substance Use Disorders

Any Internal Disorder

Any External Disorder

Lifetime History of Victimization

Acts of Physical Violence

Any (other) Illegal Activity

Three to Twelve Problems

Self-Reported in Past Year

Source: Dennis et al, under review

Co-occurring Problems are Higher for those Self-Reporting Past Year Dependence

71%

57%

25%

42%

30%37%

22%

5%

13%

22%

0%

20%

40%

60%

80%

100%

Health ProblemDistress*

Acute MentalDistress*

AcuteTraumaticDistress*

AttentionDeficit

HyperactivityDisorder*

ConductDisorder*

Past Year Dependence (n=278) Other (n=322)

Source: Tims et al., 2002 * p<.05

Evaluating the Effects of Treatment

Short Term Outcome Stability Difference between average of

early (3-6) and latter (9-12) follow-up interviews

Treatment OutcomeDifference between intake and average

of all short term follow-ups (3-12)

Long Term Stability Difference between average of short term

follow-ups (3-12) and long term follow-up (30)

Source: Dennis et al, under review, forthcoming

Month

Z-S

core

-0.60

-0.50

-0.40

-0.30

-0.20

-0.10

0.00

0 3 6 9 12

15

18

21

24

27

30

Freq. of Use

Sub. Prob.

Change in Substance Frequency Scale in CYT Experiment 1: Incremental Arm

Months from Intake

0.00

0.05

0.10

0.15

0.20

0.25

0 3 6 9 12 15 18 21 24 27 30

MET/CBT5

MET/CBT12

FSN

Source: Dennis et al, forthcoming

Treatment Outcome: -Use reduced (-34%)

- No Sig. Dif. by condition

Short Term Stability:- Outcomes stable (-1%) - No Sig. Dif. by condition

Long Term Stability:- Use increases (+64%)


Change in Number of Substance Problems in CYT Experiment 1: Incremental Arm

Months from Intake

0

1

2

3

4

5

0 3 6 9 12 15 18 21 24 27 30

MET/CBT5

MET/CBT12

FSN


Long Term Stability:-Problems increase (+17%)

-Sig. Dif. by condition (+37% vs +10% vs +7%)

Treatment Outcome: -Problems reduced (-46%)

- Sig. Dif. by condition(-50% vs. –33% vs. –51%)

Short Term Stability:-Further reductions (-25%)- No difference by condition

Change in Substance Frequency Scale inCYT Experiment 2: Alternative Arm

Months from Intake

0.00

0.05

0.10

0.15

0.20

0.25

0 3 6 9 12 15 18 21 24 27 30

MET/CBT5

ACRA

MDFT


Treatment Outcome: - Use reduced (-35%)


Short Term Stability:-Further reductions (-6%)

- Sig. Dif. by condition(+4% vs. –10% vs. –11%)

Long Term Stability:- Outcomes stable

(+20%)-No Sig. Dif. by condition

Change in Number of Substance Problems inCYT Experiment 2: Alternative Arm

Months from Intake

0

1

2

3

4

5

0 3 6 9 12 15 18 21 24 27 30

MET/CBT5

ACRA

MDFT


Long Term Stability:- Outcomes stable (+7%)-No Sig. Dif. by condition

Treatment Outcome: - Problems reduced (-43%)- No difference by condition

Short Term Stability:- Outcomes stable (-8%)


Percent in Past Month Recovery (no use or problems while living in the community)

14%17%

6%

14%11%

18%

0%

10%

20%

30%

40%

50%

0 3 6 9 12 30MET/ CBT5

0 3 6 9 12 30MET/ CBT12

0 3 6 9 12 30FSN

0 3 6 9 12 30MET/ CBT5

0 3 6 9 12 30ACRA

0 3 6 9 12 30MDFT


Cumulative Recovery Pattern at 30 months:(The Majority Vacillate in and out of Recovery)


37% Sustained Problems

5% Sustained Recovery

19% Intermittent, currently in

recovery

39% Intermittent, currently not in

recovery

Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition

Source: Dennis et al., under review; forthcoming

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

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

MET/ CBT5 MET/ CBT12 FSNM MET/ CBT5 ACRA MDFT

Experiment 1 (n=299) Experiment 2 (n=297)

Cos

t P

er P

erso

n in

Rec

over

y (C

PP

R)

* 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

Stability of MET/CBT-5

findings mixed at 30 months

Integrated family therapy (MDFT) was more cost effective than

adding it on top of treatment (FSN) at 30 months

MET/CBT-5, -12 and ACRA more cost effective at

12 months

Reduction in Average Cost to Society in CYT Experiment 1: Incremental Arm

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Intake 3 6 9 12 15 18 21 24 27 30

Months from Intake

MET/CBT5

MET/CBT12

FSNM

Source: French et al, in press; forthcoming

Includes the cost of CYT Treatment

Further Reductions

(-47%) occurred out to

30 months

Reductions (-23%) in Average

Cost to Society offset Treatment Costs within 12

months

Reduction in Average Cost to Society in CYT Experiment 2: Alternative Arm

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Intake 3 6 9 12 15 18 21 24 27 30

Months from Intake

MET/CBT5

ACRA

MDFT


Includes the cost of CYT Treatment

Average Cost to Society goes up then down and

does not offset Tx Costs within 12 months (+7%)

Further Reductions

occurred out to 30 months

(-40%)

Average Cost to Society Varied More by Site than Condition

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

0 3 6 9 12 15 18 21 24 27 30

Months from Intake

UCHC, Farmington, CT (-24%, -44%)

PAR, St. Petersburg, FL (-22%, -49%)

CHS, Madison Co., IL (-8%, -51%)

CHOP, Philadelphia, PA (+18%, -34%)


Reprise of Clinical Outcomes

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

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

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

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 PILighthouse Institute, Chestnut Health Systems720 West Chestnut, Bloomington, IL 61701Phone: (309) 827-6026, Fax: (309) 829-4661E-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)

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