Recent Efforts to Move Adolescent Substance Abuse Treatment Towards Evidenced Based Practice

Michael Dennis, Ph.D., Chestnut Health Systems, Bloomington, ILPresentation at the “Joint Conference of the Canadian Evaluation Society (CES) and the American Evaluation Association (AEA)”, Toronto, Ontario, Canada, October 24-30. 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 using data provided by the following grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888, TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340, TI130022, TI03345, TI012208, TI013323, TI14376, TI14261, TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272, TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678, TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674, TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514, TI15672, TI15478, TI15447, TI15545, TI15671)). 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) 827-6026, fax: (309) 829-4661, e-Mail: junsicker@chestnut.org

Examine epidemiological evidence on the importance of adolescent treatment for chronic substance use disorders

Review the major trends in the adolescents substance abuse treatment system

Describe the current renaissance of adolescent treatment research Describe the development of a common data base to facilitate both

experimental and non-experimental evaluations, and Provide an example of actually using it.

Goals of this Presentation

Substance Abuse and Dependence are Largely Adolescent Onset Disorders

Source: 2002 NSDUH and Dennis et al forthcoming

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

No Alcohol or Drug Use

Light Alcohol Use Only

Any Infrequent Drug Use

Regular AOD Use

Abuse

Dependence

Severity CategoryAdolescent

OnsetRemission

Increasing rate of non-

users

(2002 U.S. Household Population age 12+=

235,143,246)

Substance Use Careers Last for Decades P

erce

nt

in R

ecov

ery

302520151050

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Median duration of

27 years(IQR: 18 to

30+)

Source: Dennis et al 2005 (n=1,271)Years from first use to 1+ years abstinence

Substance Use Careers are Longer, the Younger the Age of First Use

Per

cen

t in

Rec

over

y

Years from first use to 1+ years abstinence

302520151050

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: Dennis et al 2005 (n=1,271)

under 15*

21+

15-20*

Age

of

1st U

se G

rou

ps

* p<.05 (different from 21+)

Substance Use Careers are Shorter the Sooner People get to Treatment

Per

cen

t in

Rec

over

y

Years from first use to 1+ years abstinence

302520151050

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: Dennis et al 2005 (n=1,271)

20+

0-9*

10-19*

Yea

rs t

o 1st

Tx

Gro

up

s

* p<.05 (different from 20+)

It Takes Decades and Multiple Episodes of Treatment

Years from first Tx to 1+ years abstinence

2520151050

Median duration of 9 years

(IQR: 3 to 23) and 3 to 4

episodes of care

Per

cen

t in

Rec

over

y

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: Dennis et al 2005 (n=1,271)

Adolescent Treatment Admissions have increased by 50% over the past decade

Source: Office of Applied Studies (2005) 1992- 2002 Treatment Episode Data Set (TEDS)http://www.samhsa.gov/oas/dasis.htm

50% higher than in 1992

Change in Referral Sources

Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf

JJ referrals have doubled and are driving growth

-79%

-9%-15%-26% -10%

-73%

31%155%

120%

48%

0%10%20%30%40%50%60%70%80%90%

100%A

lcoh

ol

Mar

ijua

na/H

ash

Coc

aine

/Cra

ck

Her

oin/

Opi

ates

Hal

luci

noge

ns

Met

ham

phet

amin

es

Oth

erA

mph

etam

ines

Stim

ulan

ts

Inha

lant

s

Oth

er\e

-200%

-100%

0%

100%

200%

1993 (95,271 admissions)

2003 (153,251 admissions)Change (+61%)

Others went downMethamp, Opiates,

and Cannabis grew the most

Alcohol & Cannabis Continue to be the

dominate substances

Change in Substance Problems

Source: OAS 2005

92%

3%

-3%-19% -26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Out

pati

ent

Inte

nsiv

eO

utpa

tien

t

Det

ox

Lon

g-te

rmR

esid

enti

al

Shor

t-te

rmR

esid

enti

al

-200%

-100%

0%

100%

200%

1993 (95,271 admissions) 2003 (153,251 admissions) Change (+61%)

Outpatient Continues to be the dominate modality

Change in Level of Care

Source: OAS 2005

Key Problems in the U.S. System

Less than 1/10th of adolescents with substance dependence/abuse problems receive treatment

Median length of stay was only 62.5 days Less than 75% stay the 3 months recommended by

NIDA At discharge, 40% completed, 6% transferred, 26%

dropped out, 20% were administrative discharged, and 9% left for other reasons

Even from short term residential treatment, only 7% successfully stepped down to outpatient care

Little is known about the rate of initiation after detention

Source: OAS, 2000, 2005; Hser et al., 2001

The field is increasingly facing demands from payers, policymakers, and the public at large for “evidence-based practices (EBP)” which can reliably produce practical and cost-effective interventions, therapies and medications that will

– reduce substance use and its negative consequences among those who are abusing or dependent,

– reduce the likelihood of relapse for those who are recovering, and

– reduce risks for initiating drug use among those not yet using,

Source: NIDA Blue Ribbon Panel on Health Services Research (see www.nida.nih.gov )

The Shift to Evidenced Based Practice

The Current Renaissance of Adolescent Treatment Research

Feature 1930-1997 1997-2005

Tx Studies* 16 Over 200

Random/Quasi 9 44

Tx Manuals* 0 30+

QA/Adherence Rare Common

Std Assessment* Rare Common

Participation Rates Under 50% Over 80%

Follow-up Rates 40-50% 85-95%

Methods Descriptive/Simple More Advanced

Economic Some Cost Cost, CEA, BCA

* Published and publicly available

QA/Adherence/Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)

The effect of a well implemented weak program is

as big as a strong program implemented poorly

The best is to have a strong

program implemented

well

Thus one should optimally pick the strongest intervention that one can

implement wellSource: Adapted from Lipsey, 1997, 2005

How we are building a common knowledge base about what is working for whom through

Pooling data across multiple evaluations and programs

Identifying common factors and principals that appear to hold across interventions

Having peer reviewed panels review and rate the strength of evidence on the effectiveness and generalizability of specific interventions

Conducting formal meta analysis of a groups of similar interventions that have been replicated and evaluated several times

Number of GAIN Sites

Adolescent and Adult Treatment Program Global Appraisal of Individual Needs (GAIN) Collaborators

30 to 6010 to 292 to 91

07/05One or more state or county wide systems uses the GAIN

One or more state or county wide systems considering using the GAIN

The Current Renaissance of Adolescent Treatment Research

1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of Adol. (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 38 Effective Adolescent Treatment (EAT) 2004-2007 NIAAA/CSAT’s study of diffusion of innovation 2004-2009 CSAT 22 Young Offender Re-entry Programs (YORP) 2005-2008 CSAT 20 Juvenile Drug Court (JDC) 2005-2008 CSAT 16 State Adolescent Coordinator (SAC) grants

Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN)

Need to Address Co-occurring MH Issues

49%

38%

21%

28%

32%

28%

67%

59%

48%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Internal Disorder

Depressive Disorder

Anxiety Disorder

Trauma Related Disorder

Any Self Mutilation

Any homicidal/suicidal thoughts

Any External Disorder

Conduct DisorderAttention

Deficit-Hyperactivity Disorder (ADHD)

75% have a co-occurring

MH diagnosisSource: CSAT 2004 AT Common GAIN Data set Dennis & Ives 2005

Most also have problems with violence or illegal activity…

Source: CSAT 2004 AT Common GAIN Data set Dennis & Ives 2005

86%

72%

58%

57%

51%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any violence orillegal activity

Physical Violence

Property Crimes

Drug Related Crime

InterpersonalCrimes

Past Year

Victimization is particularly intertwined with the number of problems*

Source: Dennis & Ives 2005 (odds for High over odds for Low)

0%

10%

20%30%

40%

50%60%

70%

80%90%

100%

1 Problem 2 Problems 3 Problems 4 Problems 5 or moreProblems(117.2)Low Mod. High

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

Victimization Also Interacts with Outcomes

Source: Funk, et al., 2003

0

5

10

15

20

25

30

35

40

Intake 6 Months Intake 6 Months

Mar

ijua

na U

se (

Day

s of

90)

OP -High OP - Low/Mod Resid-High Resid - Low/Mod.

CHS Outpatient CHS Residential Traumatized groups have higher severity

High trauma group does not respond to OP

Both groups respond to residential treatment

How do CHS OP’s high GVS outcomes compare with other OP programs on average?

Source: CYT and ATM Outpatient Data Set Dennis 2005

-1.00

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Z-S

core

on

Sub

stan

ce F

requ

ency

Sca

le (

SF

S) CYT Total (n=217; d=0.51)

ATM Total (n=284; d=0.41)

CHSOP (n=57; d=0.18)

Other programs serve clients who have significantly

higher severity

And on average they have moderate effect sizes even

with high GVS

Green line is CHS OP’s High GVS adolescents; they have some initial gains but substantial relapse

Which 5 OP programs did the best with high GVS adolescents?

Source: CYT and ATM Outpatient Data Set Dennis 2005

-1.00

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Z-S

core

on

Sub

stan

ce F

requ

ency

Sca

le (

SF

S) 7 Challenges (n=42; d=1.21)

Tucson Drug Court (n=27; d=0.65)

MET/CBT5a (n=34; d=0.62)

MET/CBT5b (n=40; d=0.55)

FSN/MET/CBT12 (n=34; d=0.53)

CHSOP (n=57; d=0.18)

The two best were used with much higher severity adolescents and

TDC was not manualized

Next we can check to see if they are any more similar in severity

-1.00

-0.80

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Z-S

core

on

Sub

stan

ce F

requ

ency

Sca

le (

SF

S)

MET/CBT5a (n=34; d=0.62)

MET/CBT5b (n=40; d=0.55)

FSN/MET/CBT12 (n=34; d=0.53)Epoch (n=72; d=0.33)

TSAT (n=66; d=0.35)CHSOP (n=57; d=0.18)

Which 5 OP Programs, of similar severity, did the best with high GVS adolescents?

Source: CYT and ATM Outpatient Data Set Dennis 2005

Trying MET/CBT5 because it is

stronger, cheaper, and easier to

implement

Not much improvement and they do not work quite as well

Currently CHS is doing an experiment comparing its regular OP with MET/CBT5

Areas where staff wanted more specific knowledge and interventions

Victimization, trauma and helplessness Self mutilation, para-suicidal and suicidal behaviors Anger management, violence and crime How to help their kids access mental health services (typically for internal disorders) when availability is

limited Managing ADHD and impulsivity How to get parents involved in treatment and continuing care Tobacco, opioids, and methamphetamine use, Working with schools, probation, families Females, Males, African Americans, Native Americans, Spanish Speaking adolescents and their families HIV, STI, and Liver risk How to make interventions more assertive and strength based Evaluation issues like follow-up, data management, & analysis Workforce development, including peer-to-peer on specific treatment approaches and other job functions

like MIS

Conclusions Chronic Substance Use Disorders onset during adolescents and are

related to multiple co-occurring problems. The field is demanding and shifting towards evidenced based practice. Pooling data from hundreds of local evaluations can be used to help

with needs assessment and program planning To maximize the benefit, the field needs to

– Pay attention to the combination of problems that are actually common

– Focus on interventions targeting these specific clusters of problems– Focus on interventions that are manualized/standardized, publicly

available (whether free or not), and designed to support replication– Focus on the strength of implementation and assertiveness– Report findings and/or pool data in ways that facilitate direct or

post hoc (e.g., meta analytic) comparisons and synthesis

Resources

Assessment Instruments – 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

Treatment Programs– CSAT CYT, ATM, ACC and other treatment 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

– National Registry of Effective Prevention ProgramsSubstance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov

Resources Implementing Evidenced based practice

– Central East ATTC Evidence Based Practice Resource Page http://www.ceattc.org/nidacsat_bpr.asp?id=LGBT

– Northwest Frontier ATTC Best Practices in Addiction Treatment: A Workshop Facilitator's Guide http://www.nattc.org/resPubs/bpat/index.html

– Turning Knowledge into Practice: A Manual for Behavioral Health Administrators and Practitioners About Understanding and Implementing Evidence-Based Practices http://www.tacinc.org/index/viewPage.cfm?pageId=114

– Evidence-Based Practices: An Implementation Guide for Community-Based Substance Abuse Treatment Agencies http://www.uiowa.edu/~iowapic/files/EBP%20Guide%20-%20Revised%205-03.pdf

– National Center for Mental Health and Juvenile Justice Evidence Based Practice resource list at http://www.ncmhjj.com/EBP/default.asp

– 2005 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/csatsasatepost/

– Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) www.chestnut.org/li/apss/sasate

References Cited Hereo Beutler, L. E. (2000). David and Goliath When empirical and clinical standards of practice meet. American Psychologist, 55, 997-1007.o Dennis, M.L., (2005).  Traumatic Victimization Among Adolescents Presenting for Substance Abuse Treatment - It is Time to Stop Ignoring the Elephant in our Counseling

Room.  Presentation at the 2005 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness.   Retrieved from http://www.mayatech.com/cti/csatsasatepost/pdfs1/MichaelDennisAddressingVictimizationandTrauma.pdf .

o Dennis, M.L., & Ives, M. (2005).  Recent Efforts Towards Moving Adolescent Substance Abuse Treatment Towards Evidenced Based Practice.  Presentation at the 2005 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness.   Retrieved from http://www.mayatech.com/cti/csatsasatepost/pdfs1/MichaelDennisEvidencedBased.pdf .

o Dennis & Scott (Forthcoming). Managing Substance Use Disorders (SUDS) as a Chronic Condition. NIDA Science & Perspectives. o Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28 (2S), S49-S60 .o 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 o 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.o Epstein, J. F. (2002). Substance dependence, abuse and treatment: Findings from the 2000 National Household Survey on Drug Abuse (NHSDA Series A-16, DHHS Publication

No. SMA 02-3642). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Retrieved from http://www.DrugAbuseStatistics.SAMHSA.gov.

o Funk, R. R., McDermeit (Ives), M., Godley, S. H., & Adams, L. (2003). Maltreatment issues by level of adolescent substance abuse treatment The extent of the problem at intake and relationship to early outcomes. Journal of Child Maltreatment, 8, 36-45.

o Hser, Y. I., Grella, C. E., Hubbard, R. L., Hsieh, S. C., Fletcher, B. W., Brown, B. S., & Anglin, M. D. (2001). An evaluation of drug treatments for adolescents in four U.S. cities. Archives of General Psychiatry, 58, 689-695.

o Lipsey, M. W. (1997). What can you build with thousands of bricks? Musings on the cumulation of knowledge in program evaluation. New Directions for Evaluation, 76, 7-24.o Lipsey, M.W. (2005). What Works with Juvenile Offenders: Translating Research into Practice. Adolescent Treatment Issues Conference, February 28, Tampa, FLo Lipsey, M.W., Chapman, G.L., & Landenberger, N.A. (2001).  Cognitive-Behavioral Programs for Offenders.  The ANNALS of the American Academy of Political and Social

Science, 578(1), 144-157 o Office Applied Studies (2002).   Analysis of the 2002 National Survey on Drug Use and Health (NSDUH) on line at

http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00064.xml . Office Applied Studies (2002).   Analysis of the 2002 Treatment Episode Data Set (TEDS) on line data at http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00056.xml) Office of Applied Studies. (2004). The DASIS Report Adolescent treatment admissions, 1992 and 2002. Rockville, MD: SAMHSA. Retrieved from http//oas.samhsa.gov/2k4/youthTX/youthTX.htm.

o Office of Applied Studies. (2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services. Rockville, MD: SAMHSA. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

o White, M. K., Funk, R., White, W., & Dennis, M. (2003). Predicting violent behavior in adolescent cannabis users The GAIN-CVI. Offender Substance Abuse Report, 3(5), 67-69.

o Weisner, C., McLellan, T., Barthwell, A., Blitz, C., Catalano, R., Chalk, M., Chinnia, L., Collins, R. L., Compton, W., Dennis, M. L., Frank, R., Hewitt, W., Inciardi, J. A., Lightfoot, M., Montoya, I., Sterk, C. E., Wood, J., Pintello, D., Volkow, M., & Michaud, S. E. (2004). Report of the Blue Ribbon Task Force on Health Services Research at the National Institute on Drug Abuse. Rockville, MD National Institute on Drug Abuse.

o White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2), 24-28.