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

1. Recent Efforts to Move Adolescent Substance Abuse Treatment Towards Evidenced Based Practice Michael Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL Presentation 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

2. Goals of this Presentation • 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.

3. Adolescent Onset Remission Substance Abuse and Dependence are Largely Adolescent Onset Disorders Increasing rate of non-users 100 Severity Category 90 No Alcohol or Drug Use 80 70 Light Alcohol Use Only 60 Any Infrequent Drug Use 50 40 Regular AOD Use 30 Abuse 20 10 Dependence 0 (2002 U.S. Household Population age 12+= 235,143,246) 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Source: 2002 NSDUH and Dennis et al forthcoming

4. Substance Use Careers Last for Decades 100% 90% 80% Percent in Recovery 70% Median duration of 27 years (IQR: 18 to 30+) Years from first use to 1+ years abstinence 60% 50% 40% 30% 20% 10% 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

5. Substance Use Careers are Longer, the Younger the Age of First Use 100% 90% 21+ 80% Percent in Recovery 15-20* Age of 1st Use Groups 70% Years from first use to 1+ years abstinence 60% under 15* 50% 40% 30% 20% * p<.05 (different from 21+) 10% 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

6. Substance Use Careers are Shorter the Sooner People get to Treatment 100% 0-9* 90% 80% 10-19* Years to 1st Tx Groups Percent in Recovery 70% Years from first use to 1+ years abstinence 60% 50% 40% 20+ 30% 20% 10% * p<.05 (different from 20+) 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

7. It Takes Decades and Multiple Episodes of Treatment 100% 90% 80% Percent in Recovery 70% Median duration of 9 years (IQR: 3 to 23) and 3 to 4 episodes of care Years from first Tx to 1+ years abstinence 60% 50% 40% 30% 20% 10% 0% 0 5 10 15 20 25 Source: Dennis et al 2005 (n=1,271)

8. 50% higher than in 1992 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

9. 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

10. 200% 155% 31% 120% 48% 100% 0% -9% -10% -26% -15% -100% -73% -79% -200% Alcohol & Cannabis Continue to be the dominate substances Change in Substance Problems 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Other\e Alcohol Inhalants Stimulants Hallucinogens Cocaine/Crack Amphetamines Other Heroin/Opiates Marijuana/Hash Methamphetamines Methamp, Opiates, and Cannabis grew the most Others went down 1993 (95,271 admissions) 2003 (153,251 admissions) Change (+61%) Source: OAS 2005

11. 200% Outpatient Continues to be the dominate modality 92% 100% 3% 0% -3% -19% -26% -100% -200% Change in Level of Care 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Detox Outpatient Outpatient Intensive Long-term Short-term Residential Residential 1993 (95,271 admissions) 2003 (153,251 admissions) Change (+61%) Source: OAS 2005

12. 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

13. The Shift to Evidenced Based Practice 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 )

14. The Current Renaissance of Adolescent Treatment Research * Published and publicly available

15. QA/Adherence/Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate) The best is to have a strong program implemented well The effect of a well implemented weak program is as big as a strong program implemented poorly Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

16. 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

17. One or more state or county wide systems uses the GAIN One or more state or county wide systems considering using the GAIN Adolescent and Adult Treatment Program Global Appraisal of Individual Needs (GAIN) Collaborators Number of GAIN Sites 30 to 60 10 to 29 2 to 9 1 07/05

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

19. Need to Address Co-occurring MH Issues 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Any Internal Disorder 49% Depressive Disorder 38% Anxiety Disorder 21% 28% Trauma Related Disorder 32% Any Self Mutilation Any homicidal/ suicidal thoughts 28% 67% Any External Disorder Conduct Disorder 59% 75% have a co-occurring MH diagnosis Attention Deficit-Hyperactivity Disorder (ADHD) 48% Source: CSAT 2004 AT Common GAIN Data set Dennis & Ives 2005

20. Most also have problems with violence or illegal activity… 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Past Year Any violence or 86% illegal activity Physical Violence 72% Property Crimes 58% 57% Drug Related Crime Interpersonal 51% Crimes Source: CSAT 2004 AT Common GAIN Data set Dennis & Ives 2005

21. Victimization is particularly intertwined with the number of problems* 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 Problem 4 Problems 5 or more 2 Problems 3 Problems Problems (117.2) Low Mod. High * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: Dennis & Ives 2005 (odds for High over odds for Low)

22. Traumatized groups have higher severity High trauma group does not respond to OP Both groups respond to residential treatment Victimization Also Interacts with Outcomes CHS Outpatient CHS Residential 40 35 30 25 Marijuana Use (Days of 90) 20 15 10 5 0 Intake 6 Months Intake 6 Months OP -High OP - Low/Mod Resid-High Resid - Low/Mod. Source: Funk, et al., 2003

23. 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 How do CHS OP’s high GVS outcomes compare with other OP programs on average? 1.00 CYT Total (n=217; d=0.51) 0.80 0.60 ATM Total (n=284; d=0.41) 0.40 CHSOP (n=57; d=0.18) 0.20 Z-Score on Substance Frequency Scale (SFS) 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 Source: CYT and ATM Outpatient Data Set Dennis 2005

24. The two best were used with much higher severity adolescents and TDC was not manualized 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) Next we can check to see if they are any more similar in severity Which 5 OP programs did the best with high GVS adolescents? 1.00 0.80 0.60 0.40 0.20 Z-Score on Substance Frequency Scale (SFS) 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 Source: CYT and ATM Outpatient Data Set Dennis 2005

25. MET/CBT5a (n=34; d=0.62) Trying MET/CBT5 because it is stronger, cheaper, and easier to implement 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) Not much improvement and they do not work quite as well Which 5 OP Programs, of similar severity, did the best with high GVS adolescents? 1.00 0.80 0.60 0.40 0.20 CHSOP (n=57; d=0.18) Z-Score on Substance Frequency Scale (SFS) 0.00 -0.20 -0.40 -0.60 Currently CHS is doing an experiment comparing its regular OP with MET/CBT5 -0.80 -1.00 Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12 Source: CYT and ATM Outpatient Data Set Dennis 2005

26. 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 Areas where staff wanted more specific knowledge and interventions

27. 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

28. 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

29. Resources • Implementing Evidenced based practice • Central East ATTC Evidence Based Practice Resource Pagehttp://www.ceattc.org/nidacsat_bpr.asp?id=LGBT • Northwest Frontier ATTC Best Practices in Addiction Treatment: A Workshop Facilitator's Guidehttp://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 Practiceshttp://www.tacinc.org/index/viewPage.cfm?pageId=114 • Evidence-Based Practices: An Implementation Guide for Community-Based Substance Abuse Treatment Agencieshttp://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 athttp://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

30. References Cited Here • Beutler, L. E. (2000). David and Goliath When empirical and clinical standards of practice meet. American Psychologist, 55, 997-1007. • 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 . • 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 . • Dennis & Scott (Forthcoming). Managing Substance Use Disorders (SUDS) as a Chronic Condition. NIDA Science & Perspectives. • 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 . • 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. • 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. • 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. • 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. • 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. • Lipsey, M.W. (2005). What Works with Juvenile Offenders: Translating Research into Practice. Adolescent Treatment Issues Conference, February 28, Tampa, FL • 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 • 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. • 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 . • 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. • 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. • White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2), 24-28.