State of the Art of Adolescent Substance Abuse Treatment

1
State of the Art of Adolescent Substance Abuse
Treatment

• Michael Dennis, Ph.D.
• Chestnut Health Systems,
• Normal, IL
• Presentation on February 18, 2009 for Pavillon
  Foster Addiction Treatment Centre and
  lAssociation des centres de réadaptation en
  dépendance du Québec (ACRDQ), Montreal, Quebece,
  Canada. This presentation reports on treatment
  research funded by the Center for Substance Abuse
  Treatment (CSAT), Substance Abuse and Mental
  Health Services Administration (SAMHSA) under
  contracts 270-2003-00006 and 270-07-0191, as well
  as several individual CSAT, NIAAA, NIDA and
  private foundation grants. The opinions are those
  of the author and do not reflect official
  positions of the consortium or government.
  Available on line at www.chestnut.org/LI/Posters
  or by contacting Joan Unsicker at 448 Wylie
  Drive, Normal, IL 61761, phone [phone],
  Fax [phone], e-mail junsicker_at_Chestnut.
  Org

2
Goals of this Presentation are to

• Examine the prevalence, course, and consequences
  of adolescent substance use, co-occurring
  disorders and the unmet need for treatment
  overall
• Summarize major trends in the adolescent
  substance use and treatment system
• Highlight what it takes to move the field towards
  evidenced-based practice related to assessment,
  treatment, program evaluation and planning
• Present the findings from several recent
  treatment studies on substance abuse treatment
  research, trauma and violence/crime

3
Severity of Past Year Substance Use/Disorders
(2002 U.S. Household Population age 12
235,143,246)
Dependence 5
Abuse 4
No Alcohol or
Regular AOD
Drug Use 32
Use 8
Any Infrequent
Drug Use 4
Light Alcohol
Use Only 47
Source 2002 NSDUH Dennis Scott 2007
4
Problems Vary by Age
NSDUH Age Groups
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
65
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Source 2002 NSDUH Dennis Scott 2007
5
Crime Violence by Substance Severity
Age 12-17
Source NSDUH 2006
6
Family, Vocational MH by Substance Severity
Age 12-17
Source NSDUH 2006
7
Higher Severity is Associated with Higher Annual
Cost to Society Per Person
4,000
Median (50th percentile)
3,500
3,000
2,500
2,000
1,500
1,000
725
406
500
231
231
0
0
0
No Alcohol or
Light Alcohol
Regular AOD
Any
Dependence
Abuse
Infrequent
Drug Use
Use Only
Drug Use
Use
Source 2002 NSDUH Dennis Scott 2007
8
Brain Activity on PET Scan After Using Cocaine
Rapid rise in brain activity after taking cocaine
Actually ends up lower than they started
Photo courtesy of Nora Volkow, Ph.D. Mapping
cocaine binding sites in human and baboon brain
in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL,
Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J,
Bendreim B, Gatley ST. et al. Synapse
19894(4)371-377.
9
Brain Activity on PET Scan After Using Cocaine
With repeated use, there is a cumulative effect
of reduced brain activity which requires
increasingly more stimulation (i.e., tolerance)
Normal
Cocaine Abuser (10 days)
Even after 100 days of abstinence activity is
still low
Cocaine Abuser (100 days)
Photo courtesy of Nora Volkow, Ph.D. Volkow ND,
Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey
SL. Long-term frontal brain metabolic changes in
cocaine abusers. Synapse 11184-190, 1992 Volkow
ND, Fowler JS, Wang G-J, Hitzemann R, Logan J,
Schlyer D, Dewey 5, Wolf AP. Decreased dopamine
D2 receptor availability is associated with
reduced frontal metabolism in cocaine abusers.
Synapse 14169-177, 1993.
10
Still not back to normal after 7 years
Image courtesy of Dr. GA Ricaurte, Johns Hopkins
University School of Medicine
11
Adolescent Brain Development Occurs from the
Inside to Out and from Back to Front
Photo courtesy of the NIDA Web site. From A Slide
Teaching Packet The Brain and the Actions of
Cocaine, Opiates, and Marijuana.
12
Substance Use Careers Last for Decades
1.0
Median of 27 years from first use to 1 years
abstinence
.9
Cumulative Survival
.8
.7
Years from first use to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
30
25
20
15
10
5
0
Source Dennis et al., 2005
13
Substance Use Careers are Longer the Younger the
Age of First Use
Age of 1st Use Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
.6
.5
under 15
.4
15-20
.3
.2
21
.1
0.0
plt.05 (different from 21)
30
25
20
15
10
5
0
Source Dennis et al., 2005
14
Substance Use Careers are Shorter the Sooner
People Get to Treatment
Year to 1st Tx Groups
1.0
.9
.8
Cumulative Survival
.7
Years from first use to 1 years abstinence
20
.6
.5
.4
.3
10-19
.2
.1
0.0
0-9
plt.05 (different from 20)
30
25
20
15
10
5
0
Source Dennis et al., 2005
15
Treatment Careers Last for Years
1.0
.9
Cumulative Survival
.8
Median of 3 to 4 episodes of treatment over 9
years
.7
Years from first Tx to 1 years abstinence
.6
.5
.4
.3
.2
.1
0.0
25
20
15
10
5
0
Source Dennis et al., 2005
16
Lifetime Diagnosis and Remission Rates
100
90
83
77
80
66
70
58
56
60
48
50
39
40
31
25
30
20
20
15
13
8
7
10
15
12
11
10
10
7
3
0
Alcohol or
Alcohol
Drug Disorder
Externalizing
Mood
Anxiety
Posttraumatic
Other Drug
Disorder
disorder
Disorder
Disorder
Stress
disorder
Disorder
Lifetime Diagnosis
Past Year Remission
Remission Rate
Source Dennis, Coleman, Scott Funk
forthcoming National Co morbidity Study
Replication
17
Key Implications

• Adolescence is the peak period of risk for and
  actual on-set of substance use disorders
• Adolescent substance use can have short and long
  terms costs to society
• There are real and often lasting consequence of
  adolescent substance use on brain functioning and
  brain development
• Earlier Intervention during adolescence and young
  adult hood can reduce the duration of addiction
  careers

18
Comparison of US CN Adolescents Adults
Cannabis the most common other drug
Source Vega et al 2002 (using data from
1994-98)
19
Smoking Tobacco is Associated with More Frequent
Alcohol Cannabis Use
Source Davis 2004 Canadian Addiction Survey
20
Change in Adolescent Past Year Cannabis Use
Canada has had the highest rate of the 31 HBSC
Study Countries
45
40
2002
2006
40
38
35
All Went Down
35
31
31
30
30
27
27
25
24
25
23
22
21
20
15
10
5
0
Spain
Wales
France
Canada
England
Scotland
Slovenia
Belgium
Denmark
Switzerland
United States
Czech Republic
The Netherlands
Source Kuntsche et al 2009, Health Behaviour in
School-Aged Children (HBSC) study.
21
Past Year Alcohol or Drug Abuse or Dependence
8.9 National (but lots of geographic variation)
Source OAS, 2006 2003, 2004, and 2005 NSDUH
22
GAP between Adolescent SUD Treatment
Source OAS, 2006 2003, 2004, and 2005 NSDUH
23
Trends in Adolescent (Age 12-17) Treatment
Admissions in the U.S.
15 drop off from 160,750 in 2002 to 136,660 in
2006
69 increase from 95,017 in 1992 to 160,750 in
2002
Source Office of Applied Studies 1992- 2005
Treatment Episode Data Set (TEDS)
http//www.samhsa.gov/oas/dasis.htm
24
Median Length of Stay is only 50 days
Median Length of Stay

Total
50 days
(61,153 discharges)
Less than 25 stay the 90 days or longer time
recommended by NIDA Researchers
LTR
49 days
(5,476 discharges)
STR
21 days
(5,152 discharges)
Level of Care
Detox
3 days
(3,185 discharges)
IOP
46 days
(10,292 discharges)
Outpatient
59 days
(37,048 discharges)
0
30
60
90
Source Data received through August 4, 2004 from
23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD,
ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies
(OAS 2005). Treatment Episode Data Set (TEDS)
2002. Discharges from Substance Abuse Treatment
Services, DASIS Series S-25, DHHS Publication
No. (SMA) 04-3967, Rockville, MD Substance Abuse
and Mental Health Services Administration.
Retrieved from http//wwwdasis.samhsa.gov/teds02/2
002_teds_rpt_d.pdf .
25
53 Have Unfavorable Discharges
Despite being widely recommended, only 10 step
down after intensive treatment
Source Data received through August 4, 2004 from
23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD,
ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies
(OAS 2005). Treatment Episode Data Set (TEDS)
2002. Discharges from Substance Abuse Treatment
Services, DASIS Series S-25, DHHS Publication
No. (SMA) 04-3967, Rockville, MD Substance Abuse
and Mental Health Services Administration.
Retrieved from http//wwwdasis.samhsa.gov/teds02/2
002_teds_rpt_d.pdf .
26
Summary of Problems in the Treatment System

• The public systems is changing size, referral
  source, and focus
• Less than 50 stay 50 days (7 weeks)
• Less the 25 stay the 3 months recommended by
  NIDA researchers
• Less than half have positive discharges
• After intensive treatment, less than 10 step
  down to outpatient care
• Major problems are not reliably assessed (if at
  all)
• Difficult to link assessment data to placement or
  treatment planning decisions

27
So what does it mean to move the field towards
Evidence Based Practice (EBP)?

• Introducing explicit intervention protocols that
  are
• Targeted at specific problems/subgroups and
  outcomes
• Having explicit quality assurance procedures to
  cause adherence at the individual level and
  implementation at the program level
• Having the ability to evaluate performance and
  outcomes
• For the same program over time,
• Relative to other interventions
• Introducing reliable and valid assessment that
  can be used
• At the individual level to immediately guide
  clinical judgments about diagnosis/severity,
  placement, treatment planning, and the response
  to treatment
• At the program level to drive program evaluation,
  needs assessment, performance monitoring and long
  term program planning

28
Major Predictors of Bigger Effects

• Chose a strong intervention protocol based on
  prior evidence
• Used quality assurance to ensure protocol
  adherence and project implementation
• Used proactive case supervision of individual
• Used triage to focus on the highest severity
  subgroup

29
Impact of the numbers of Favorable features on
Recidivism (509 JJ studies)
Average Practice
Source Adapted from Lipsey, 1997, 2005
30
Cognitive Behavioral Therapy (CBT) Interventions
that Typically do Better than Usual Practice in
Reducing Recidivism (29 vs. 40)

• Aggression Replacement Training
• Reasoning Rehabilitation
• Moral Reconation Therapy
• Thinking for a Change
• Interpersonal Social Problem Solving
• MET/CBT combinations and Other manualized CBT
• Multisystemic Therapy (MST)
• Functional Family Therapy (FFT)
• Multidimensional Family Therapy (MDFT)
• Adolescent Community Reinforcement Approach
  (ACRA)
• Assertive Continuing Care

NOTE There is generally little or no
differences in mean effect size between these
brand names
Source Adapted from Lipsey et al 2001, Waldron
et al, 2001, Dennis et al, 2004
31
Need for Short Protocols Targeted at Specific
Issues

• Detoxification services and medication,
  particularly related to opioid and
  methamphetamine use
• Tobacco cessation
• Adolescent psychiatric services related to
  depression, anxiety, ADHD, and conduct disorder
• Trauma, suicide ideation, parasuicidal behavior
• Need for child maltreatment interventions (not
  just reporting protocols)
• HIV Intervention to reduce high risk pattern of
  sexual behavior
• Anger Management
• Problems with family, school, work, and probation
• Recovery coaches, recovery schools, recovery
  housing and other adolescent oriented self help
  groups / services

32
Implementation is Essential (Reduction in
Recidivism from .50 Control Group Rate)
Thus one should optimally pick the strongest
intervention that one can implement well
Source Adapted from Lipsey, 1997, 2005
33
On-site proactive urine testing can be used to
reduce false negatives by more than half
Reduction in false negative reports at no
additional cost
Effects grow when protocol is repeated
34
Implications of Implementation Science

• Can identify complex and simple protocols that
  improve outcomes
• Interventions have to be reliably delivered in
  order to achieve reliable outcomes
• Simple targeted protocols can make a big
  difference
• Need for reliable assessment of need,
  implementation, and outcomes

35
GAIN Clinical Collaborators Adolescent and Adult
Treatment Program
New Hampshire
Washington
Vermont
Maine
North
Montana
Dakota
Minnesota
Oregon
Massachusetts
South
Wisconsin
Idaho
Dakota
New York
Michigan
Wyoming
Rhode Island
Pennsylvania
Iowa
Connecticut
Nebraska
Ohio
Nevada
New Jersey
Indiana
Illinois
Utah
W. Virginia
Delaware
Colorado
California
Kansas
Virginia
Missouri
Kentucky
Maryland
North Carolina
Tennessee
District Of Columbia
Oklahoma
New Mexico
Arkansas
South Carolina
Arizona
Number of GAIN Sites
Georgia
Mississippi
0
Alabama
1 to 10
Texas
11 to 25
Louisiana
26 to 130
Alaska
GAIN State System
Florida
GAIN-SS State or
County System
Hawaii
Virgin Islands
Puerto Rico
10/07
36
CSAT GAIN Data (n15,254)
CSAT data dominated by Male, Caucasians, age 15
to 17
CSAT data dominated by Outpatient
CSAT residential more likely to be over 30 days
Any Hispanic ethnicity separate from race group.
Sources CSAT AT 2007 dataset subset to
adolescent studies (includes 2 18 or older).
37
Substance Use Problems
Source CSAT 2007 AT Outcome Data Set (n12,601)
38
Past Year Substance Severity by Level of Care
Note OPOutpatient, IOPIntensive Outpatient
LTR Long Term Residential (90 days) MTR
Moderate Term Residential (30-90 days) STRShort
Term Residential (0-30 days) Source CSAT 2007
AT Outcome Data Set (n12,824)
39
Past 90 day HIV Risk Behaviors
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
40
Sexual Partners by Level of Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
41
Co-Occurring Psychiatric Problems
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
42
Co-Occurring Psychiatric Diagnoses by Level of
Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
43
Severity of Victimization by Level of Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
44
Severity of Victimization by Gender
Source CSAT 2007 AT Outcome Data Set (n15,254)
45
Past Year Violence Crime
Dealing, manufacturing, prostitution, gambling
(does not include simple possession or use)
Source CSAT AT 2007 dataset subset to adolescent
studies (N15,254)
46
Type of Crime by Level of Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
47
Multiple Problems are the Norm
Few present with just one problem (the focus of
traditional research)
Most acknowledge 1 problems
In fact, 45present acknowledging 5 major
problems
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
48
Number of Problems by Level of Care
Source CSAT 2007 AT Outcome Data Set (n12,824)
49
No. of Problems by Severity of Victimization
Those with high lifetime levels of victimization
have 117 times higher odds of having 5 major
problems
Severity of Victimization
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
50
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 Childrens
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
51
Context Circa 1997

• Cannabis had become more potent, was associated
  with a wide of problems (particularly when
  combined with alcohol), and had become the
  leading substances mentioned in arrests,
  emergency room admissions, autopsies, and
  treatment admissions (doubling in in 5 years)
• Over 80 of adolescents with Cannabis problems
  were being seen in outpatient setting
• The median length of stay was 6 weeks, with only
  25 making it 3 months
• There were no published manuals targeting
  adolescent marijuana users in outpatient
  treatment
• The purpose of CYT was to manualize five
  promising protocols, field test their relative
  effectiveness, cost, and benefit-cost and provide
  them to the field

Source Dennis et al, 2002
52
Two Effectiveness Experiments
Trial 2
Trial 1
Incremental Arm
Alternative Arm
Source Dennis et al, 2002
53
Actual Treatment Received by Condition
ACRA and MDFT both rely on individual, family and
case management instead of group
FSN adds multi family group, family home visits
and more case management
And MDFT using more family therapy
MET/CBT12 adds 7 more sessions of group
With ACRA using more individual therapy
Source Dennis et al, 2004
54
Average Episode Cost (US) of Treatment
--------------------------------------------Econo
mic Cost------------------------------------------
--------- Director Estimate-----
4,000
3,322
3,500
3,000
2,500
Average Cost Per Client-Episode of Care
1,984
2,000
1,559
1,413
1,500
1,197
1,126
1,000
500
-
ACRA (12.8 weeks)
MET/CBT5 (6.8 weeks)
MET/CBT5 (6.5 weeks)
MET/CBT12 (13.4 weeks)
FSN (14.2 weeks w/family)
MDFT(13.2 weeks w/family)
Source French et al., 2002
55
CYT Increased Days Abstinent and Percent in
Recovery
90
90
Days Abstinent
80
80
Percent in Recovery
70
70
60
60
50
50
Days Abstinent Per Quarter
in Recovery at the End of the Quarter
40
40
30
30
20
20
10
10
0
0
Intake
3
6
9
12
no use, abuse or dependence problems in the past
month while in living in the community
Source Dennis et al., 2004
56
Similarity of Clinical Outcomes by Conditions
Not significantly different by condition.
Trial 1
Trial 2
300
50
.
280
40
.
260
30
over 12 months
at Month 12
Total days abstinent
Percent in Recovery
240
20
220
10
200
0
MET/ CBT5
MET/
FSN
MET/ CBT5
ACRA
MDFT
(n102)
CBT12
(n102)
(n99)
(n100)
(n99)
269
256
260
251
265
257
Total Days Abstinent
0.28
0.17
0.22
0.23
0.34
0.19
Percent in Recovery
n.s.d., effect size f0.06
n.s.d., effect size f0.06
n.s.d., effect size f0.12
n.s.d., effect size f0.16
Source Dennis et al., 2004
57
Moderate to large differences in
Cost-Effectiveness by Condition
Trial 2
Trial 1
20
20,000
16
16,000
12
12,000
Cost per person in recovery
at month 12
over 12 months
Cost per day of abstinence
8
8,000
4
4,000
0
0
MET/
MET/ CBT5
FSN
MET/ CBT5
ACRA
MDFT
CBT12
4.91
6.15
15.13
9.00
6.62
10.38
CPDA
CPPR
3,958
7,377
15,116
6,611
4,460
11,775
plt.05 effect size f0.48
plt.05 effect size f0.22
plt.05, effect size f0.72
plt.05, effect size f0.78
Source Dennis et al., 2004
58
36 Site Replication on MET/CBT5
WA
NH
ME
VT
MT
ND
OR
MN
MA
NY
WI
ID
SD
MI
WY
RI
CT
PA
IA
NE
NJ
IL
OH
IN
NV
UT
DE
WV
CO
VA
CA
KS
MD
KY
MO
DC
NC
TN
OK
AZ
AR
NM
SC
GA
AL
MS
CYT 4 Sites
TX
LA
FL
AK
HI
Source Dennis, Ives, Muck, 2008
59
Range of Effect Sizes (d) for Change in Days of
Abstinence (intake to 12 months) by Site
1.40
1.40
6 programs completely above CYT
1.20
1.20
1.00
1.00
0.80
0.80
Cohens d
0.60
0.60
0.40
0.40
0.20
0.20
75 above CYT median
0.00
0.00
4 CYT Sites (f0.39) (median within site d0.29)
36 EAT Sites (f0.21) (median within site d0.49)
Source Dennis, Ives, Muck, 2008
60
Cumulative Recovery Pattern at 30 months
5 Sustained
Recovery
37 Sustained
19 Intermittent,
Problems
currently in
recovery
39 Intermittent,
currently not in
recovery
The Majority of Adolescents Cycle in and out of
Recovery
Source Dennis et al, forthcoming
61
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents


Incarcerated

(46 stable)
In the

In Recovery
Community

(62 stable)
Using


(75 stable)






Avg of 39 change status each quarter
In Treatment

(48 stable)

Source 2006 CSAT AT data set
62
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents

• Probability of Going from Use to Early Recovery
  ( good)
• Age (0.8) Female (1.7),
• Frequency Of Use (0.23) Non-White (1.6)
• Self efficacy to resist relapse (1.4)
• Substance Abuse Treatment Index (1.96)

In the
12

In Recovery
Community

(62 stable)
Using


27
(75 stable)



Probability of from Recovery to Using (
good) - Freq. Of Use (0.0002) Initial Weeks
in Treatment (1.03) - Illegal Activity (0.70)
Treatment Received During Quarter (2.00) - Age
(0.81) Recovery Environment (r) (1.45)
Positive Social Peers (r) (1.43)

• Average days during transition period of
  participation in self help, AOD free structured
  activities and inverse of AOD involved
  activities, violence, victimization,
  homelessness, fighting at home, alcohol or drug
  use by others in home
• Proportion of social peers during transition
  period in school/work, treatment, recovery, and
  inverse of those using alcohol, drugs, fighting,
  or involved in illegal activity.

63
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents

• Probability of Going from Use to Treatment (
  good)
• Age (0.7) Times urine Tested (1.7),
• Treatment Motivation (1.6)
• Weeks in a Controlled Environment (1.4)

In the

Community

Using


(75 stable)



7



In Treatment

(48 v 35 stable)

Source 2006 CSAT AT data set
64
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents

• Probability of Going to Using vs. Early
  Recovery ( good)
• - Baseline Substance Use Severity (0.74)
  Baseline Total Symptom Count (1.46)
• - Past Month Substance Problems (0.48) Times
  Urine Screened (1.56)
• - Substance Frequency (0.48) Recovery
  Environment (r) (1.47)
• 
  Positive Social Peers (r) (1.69)

In the

In Recovery
Community

(62 stable)
Using


(75 stable)



26
19

• Average days during transition period of
  participation in self help, AOD free structured
  activities and inverse of AOD involved
  activities, violence, victimization,
  homelessness, fighting at home, alcohol or drug
  use by others in home
• Proportion of social peers during transition
  period in school/work, treatment, recovery, and
  inverse of those using alcohol, drugs, fighting,
  or involved in illegal activity.

In Treatment

(48 v 35 stable)

Source 2006 CSAT AT data set
65
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents


Incarcerated

(46 stable)
10
20
In the

In Recovery
Community

(62 stable)
Using


(75 stable)








Average days during transition period of
participation in self help, AOD free structured
activities and inverse of AOD involved
activities, violence, victimization,
homelessness, fighting at home, alcohol or drug
use by others in home
Source 2006 CSAT AT data set
66
Recovery by Level of Care
100
Outpatient (79, -1)
90
Residential(143, 17)
80
Post Corr/Res (220, 18)
70
CC better
60
Percent in Past Month Recovery
50
OP Resid Similar
40
30
20
10
0
Pre-Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
Recovery defined as no past month use, abuse,
or dependence symptoms while living in the
community. Percentages in parentheses are the
treatment outcome (intake to 12 month change) and
the stability of the outcomes (3months to 12
month change) Source CSAT Adolescent Treatment
Outcome Data Set (n-9,276)
67
Findings from the Assertive Continuing Care
(ACC) Experiment

• 183 adolescents admitted to residential substance
  abuse treatment
• Treated for 30-90 days inpatient, then discharged
  to outpatient treatment
• Random assignment to usual continuing care (UCC)
  or assertive continuing care (ACC)
• Over 90 follow-up 3, 6, 9 months post
  discharge

Source Godley et al 2002, 2007
68
Time to Enter Continuing Care and Relapse after
Residential Treatment (Age 12-17)
100
90
80
70
Relapse
60
Percent of Clients
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source Godley et al., 2004 for relapse and 2000
Statewide Illinois DARTS data for CC admissions
69
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)

70
Assertive Continuing Care (ACC)Hypotheses
Assertive Continuing Care
71
ACC Improved Adherence
100
20
30
10
40
50
60
70
80
90
0
Weekly
Tx
Weekly 12 step meetings
Relapse prevention
Communication skills training
Problem solving component
Regular urine tests
Meet with parents 1-2x month
Weekly telephone contact
Contact w/probation/school
Referrals to other services
Follow up on referrals
Discuss probation/school compliance
Adherence Meets 7/12 criteria
Source Godley et al 2002, 2007
72
GCCA Improved Early (0-3 mon.) Abstinence
100
90
80
70
60
50
38
36
40
30
24
20
10
0
Any AOD (OR2.16)
Alcohol (OR1.94)
Marijuana (OR1.98)
Low (0-6/12) GCCA
Source Godley et al 2002, 2007
73
Early (0-3 mon.) Abstinence Improved Sustained
(4-9 mon.) Abstinence
100
90
80
70
60
50
40
30
22
22
19
20
10
0
Any AOD (OR11.16)
Alcohol (OR5.47)
Marijuana (OR11.15)
Early(0-3 mon.) Relapse
Source Godley et al 2002, 2007
74
Post script on ACC

• The ACC intervention improved adolescent
  adherence to the continuing care expectations of
  both residential and outpatient staff doing so
  improved the rates of short term abstinence and,
  consequently, long term abstinence.
• Despite these GAINs, many adolescents in ACC (and
  more in UCC) did not adhere to continuing care
  plans.
• The ACC1 main findings are published and findings
  from two subsequent experiments are currently
  under review
• CSAT is currently replicating ACRA/ACC in 32
  sites
• The ACC manual is being distributed via the
  website and the CD you have been provided.

75
Need for Tracks, Phases and Continuing Care

• Almost a third of the adolescents are returning
  to treatment, 23 for the second or more time
• We need to understand what did and did not work
  the last time and have alternative approaches
• We need tracks or phases that recognize that they
  may need something different or be frustrated by
  repeating the same material again and again
• We need to have better step down and continuing
  care protocols

76
Recommendations for Further Developments

• Evidenced based interventions can come from both
  research and practice
• Evidence based interventions can improve
  implementation of treatment and treatment
  outcomes
• Practice based evidence can be used to improve
  outcomes and is of equal importance
• Evidenced based interventions and their outcomes
  can be replicated in practice
• Continuing care and is a key determinant of long
  term outcomes

77
The Growing Number of GAIN Sites in Canada
GAIN Instrument Used
GAIN-I
GAIN-SS
YT
NT
Pt Hope Simpson
St Anthony
NF
Bonavista
Churchill Falls
Pt Saunders
Clarenville
Deer Lake
BC
Creston
Corner Brook
QC
Whitbourne
Stephenville
AB
SK
Burgeo
MB
Squamish
Burin Bay Arm
Calgary
PE
ON
Vancouver
NB
NS
Kenora
Montreal
Richmond
Kirkland
Pembroke
Sault Ste Marie
Cornwall
Oshawa
Toronto
Ajax
Hamilton
Burlington
London