Developing Effective Drug Treatment For Adolescents: Results from the Cannabis Youth Treatment CYT T

1
Developing Effective Drug TreatmentFor
Adolescents Results from the Cannabis Youth
Treatment (CYT) Trials

• Michael Dennis, Ph.D.
• Chestnut Health Systems
• Bloomington, IL
• Scientific Approaches to Improving Practice
  Panel Presentation at the American Society of
  Addiction Medicine (ASAM) 2004 Annual Conference,
  Washington, DC, April 25, 2004. The opinions are
  those of the author do not reflect official
  positions of the government . Available on-line
  at www.chestnut.org/li/posters.

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AcknowledgementThis 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 (CSATs) 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 .
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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
4
Objectives

• Describe the development of manual-guided,
  cost-effective, outpatient treatment
  interventions for adolescent drug abusers.
• Summarize methodological advances in assessment,
  retention, supervision, and follow-up
• Summarize evidence on their cost, effectiveness,
  and cost-effectiveness
• Examine the diffusion of these methodological and
  substantive advances to the field.

5
The Adolescent Marijuana Problem (circa
1997-1998)

• Use was starting at younger ages
• Was at an historically high level among
  adolescents
• Potency increased 3-fold from 1980 to 1997
• Was three times more likely to lead to dependence
  among adolescents than adults
• Was associated with many health, mental and
  behavioral problems
• Was the leading substance mentioned in adolescent
  emergency room admissions and autopsies

6
The State of Adolescent Treatment(circa
1997-1998)

• 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 were entering outpatient treatment
• Over 75 received less than 90 days of treatment
  (median of 6 weeks)
• Evaluations of existing adolescent outpatient
  treatment suggest that adult models or less than
  90 days of outpatient treatment is rarely
  effective for reducing marijuana use.
• No empirically evaluated treatment manuals were
  publicly available to help expand or enhance the
  system

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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,
  cost-effectiveness, and benefit cost 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.

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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 ASAM 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)

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Two Trials or Study Arms
Trial 2
Trial 1
Incremental Arm
Alternative Arm
Randomly Assigns to
Randomly Assigns to
MET/CBT5
MET/CBT5
Motivational Enhancement Therapy/
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12
ACRA
Motivational Enhancement Therapy/
Adolescent Community
Reinforcement Approach(12 weeks)
Cognitive Behavioral Therapy (12 weeks)
MDFT
FSN
Family Support Network
Multidimensional Family Therapy
Plus MET/CBT12 (12 weeks)
(12 weeks)
Source Dennis et al, 2002
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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, Godley et al, in press
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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, 2003
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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
• 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, in press
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Adolescent Cannabis Users in CYT were as or More
Severe Than Those in TEDS
Source Tims et al, 2002
14
Demographic Characteristics
Source Tims et al, 2002
15
Institutional Involvement
Source Tims et al, 2002
16
Patterns of Substance Use

100
73
80
71
60
40
17
20
9
0
Weekly Alcohol
Weekly
Weekly
Significant Time
Tobacco Use
Cannabis Use
Use
in Controlled
Environment
Source Tims et al, 2002
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Multiple Problems are the NORM
Self-Reported in Past Year
Source Dennis et al, under review
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Co-occurring Problems are Higher for those
Self-Reporting Past Year Dependence
Source Tims et al., 2002

plt.05
19
CYT Increased Days Abstinent and Percent in
Recovery (no use or problems while in community)
Source Dennis et al., in press
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Similarity of Clinical Outcomes by Conditions
Source Dennis et al., in press.
21
Moderate to large differences in
Cost-Effectiveness by Condition
Source Dennis et al., in press
22
Evaluating the Long Term Effects of Treatment
Month
Z-Score
Source Dennis et al, under review, forthcoming
23
Cumulative Recovery Pattern at 30 months(The
Majority Vacillate in and out of Recovery)
Source Dennis et al, forthcoming
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Cost Per Person in Recovery at 12 and 30 Months
After Intake by CYT Condition

Trial 1 (n299)
Trial 2 (n297)
Cost Per Person in Recovery (CPPR)
30,000
25,000
20,000
15,000
10,000
5,000
0
MET/ CBT5
MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
3,958
7,377
15,116
6,611
4,460
11,775
CPPR at 12 months
Plt.0001, Cohens f 1.42 and 1.77 at 12
months Plt.0001, Cohens f 0.76 and 0.94 at 30
months
Source Dennis et al., in press forthcoming
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Average Cost to Society Varied More by Site than
Condition
6,000
5,000
4,000
3,000
2,000
1,000
0
0
3
6
9
12
15
18
21
24
27
30
Months from Intake
Source French et al, 2003 forthcoming
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How does CYT compare with Regular OP/IOP
Frequency of Substance Use
27
How does CYT compare with Regular OP/IOP
Substance Abuse/Dependence Problems
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Dissemination and Impact

• Papers published on design, validation,
  characteristics, matching, clinical contrast,
  treatment manuals, therapist reactions, 6 month
  outcomes, cost, benefit cost
• Papers with main clinical and cost-effectiveness
  findings at 12 months in press and 30 month
  findings being submitted this year.
• Interventions being replicated as part of over
  four dozen studies currently or about to go into
  the field
• 20 to 30,000 copies of each of the 5 manuals
  distributed to policy makers, providers,
  individual clinicians and training programs (via
  NCADI or www.chestnut.org/li/apss )
• The Global Appraisal of Individual Needs (GAIN)
  assessment has been used in over 70 subsequent
  adolescent treatment studies and combined into
  one large data base that will be used to support
  case mix adjustments, benchmarking and meta
  analysis
• Supervision, Retention, and Follow-up models also
  being replicated in these adolescent treatment
  studies

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CYT was part of a Renascence of Adolescent
Treatment Research/Practice
From 1998 to 2002 the number of adolescent
treatment studies doubled and has doubled again
in the past 2 years with over 100 currently in
the field Source Dennis , White (2003) at
www.drugstrategies.org.
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CSATs Adolescent Treatment Programs
Currently Using the GAIN or CYT Txs
CSAT Grantees
Other Collaborators
Cannabis Youth Treatment (CYT)
RWJF Reclaiming Futures Program
Adolescent Treatment Model (ATM)
RWJF Other RWJF Grantees
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
NIAAA/NIDA Other Grantees
Effective Adolescent Treatment (EAT)
Other CSAT Grantees
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Conclusions

• The CYT interventions provide replicable models
  of effective 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.
• Adolescent treatment can be cost effective and
  cost beneficial to society
• CYT also helped to spur a new wave of
  methodological improvements related to
  assessment, supervision, retention, and follow-up
  that benefit researchers, evaluators, and program
  planners

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Contact Information

• Michael L. Dennis, Ph.D., CYT Coordinating Center
  PI
• Lighthouse Institute, Chestnut Health Systems
• 720 West Chestnut, Bloomington, IL 61701
• Phone [phone], Fax [phone]
• E-Mail Mdennis_at_Chestnut.Org
• Manuals and Additional Information are Available
  at
• CYT www.health.org/govpubs or
  www.chestnut.org/li/bookstore
• PETSA www.samhsa.gov/centers/csat/csat.html
  
• (then select PETS from program resources)
• APSS www.chestnut.org/li/APSS
• (copies of CYT and over a dozen other
  adolescent treatment
• manuals and information on the Society for
  Adolescent
• Substance Abuse Treatment Effectiveness
  (SASATE)

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CYT Related 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), 58-69.
• Buchan, B. J., Dennis, M. L., Tims, F. M.,
  Diamond, G. S. (2002). Cannabis use Consistency
  and validity of self report, on-site urine
  testing, and laboratory testing. Addiction,
  97(Suppl. 1), 98-108.
• 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. (in press). The Cannabis Youth
  Treatment (CYT) Study Main Findings from Two
  Randomized Trials. Journal of Substance Abuse
  Treatment.
• 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. 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.
• Dennis, M. L., Titus, J. C., Diamond, G.,
  Donaldson, J., Godley, S. H., Tims, F., Webb, C.,
  Kaminer, Y., Babor, T., Roebuck, M. C., Godley,
  M. D., Hamilton, N., Liddle, H., Scott, C. K.,
  CYT Steering Committee. (2002). The Cannabis
  Youth Treatment (CYT) experiment Rationale, study
  design, and analysis plans. Addiction, 97 (Suppl.
  1), S16-S34.
• 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., White,M.A., Titus, J.C. Godley,
  M.D. (in press). The effectiveness of
  adolescent substance abuse treatment a brief
  summary of studies through 2002. (prepared for
  Drug Strategies adolescent treatment handbook).
  Bloomington, IL Chestnut Health Systems.
• 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.

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CYT Related References - continued

• Godley, M.D., Kahn, J.H., Dennis, M.L., Godley,
  S.H., Funk, R.R. (in press). The stability and
  impact of environmental factors on substance use
  and problems after adolescent outpatient
  treatment. Psychology of Addictive Behavior.
• Godley, S. H., White, W. L., Diamond, G.,
  Passetti, L., Titus, J. (2001). Therapists'
  reactions to manual-guided therapies for the
  treatment of adolescent marijuana users. Clinical
  Psychology Science and Practice, 8(4), 405-417.
• Godley, S. H., Meyers, R. J., Smith, J. E.,
  Godley, M. D., Titus, J. M., Karvinen, T., Dent,
  G., Passetti, L., Kelberg, P. (2001). The
  Adolescent Community Reinforcement Approach
  (ACRA) for adolescent cannabis users (Cannabis
  Youth Treatment (CYT) Manual Series, No. Volume
  4). Rockville, MD Center for Substance Abuse
  Treatment, Substance Abuse and Mental Health
  Services Administration.
• Hamilton, N., Brantley, L., Tims, F., Angelovich,
  N., McDougall, B. (2001). Family Support
  Network (FSN) for adolescent cannabis users
  (Cannabis Youth Treatment (CYT) Manual Series,
  No. Volume 3). Rockville, MD Center for Substance
  Abuse Treatment, Substance Abuse and Mental
  Health Services Administration.
• Jensen, K. A. (2001). The effects of adolescent
  peer-based intervention Contextual influence of
  peers during cannabis treatment. University of
  South Florida.
• Liddle, H. A. (2002). Multidimensional Family
  Therapy (MDFT) for adolescent cannabis users
  (Cannabis Youth Treatment (CYT) Manual Series,
  No. Volume 5). Rockville, MD Center for Substance
  Abuse Treatment, Substance Abuse and Mental
  Health Services Administration.
• Petry, N. M., Tawfik, Z. (2001). A comparison
  of problem gambling and non-problem gambling
  youth seeking treatment for marijuana abuse.
  Journal of the American Academy of Child and
  Adolescent Psychiatry, 40(11), 1324-1331.
• Roebuck, M. C., French, M. T., Dennis, M. L.
  (2004). Adolescent marijuana use and school
  attendance. Economics of Education Review, 23(2),
  145-153.
• Sampl, S., Kadden, R. (2001). Motivational
  Enhancement Therapy and Cognitive Behavioral
  Therapy for Adolescent Cannabis Users 5 Sessions
  (Cannabis Youth Treatment (CYT) Manual Series,
  No. Volume 1). Rockville, MD Center for Substance
  Abuse Treatment, Substance Abuse and Mental
  Health Services Administration.
• Tims, F. M., Dennis, M. L., Hamilton, N., Buchan,
  B. J., Diamond, G. S., Funk, R., Brantley, L.
  B. (2002). Characteristics and problems of 600
  adolescent cannabis abusers in outpatient
  treatment . Addiction, 97, 46-57.
• Titus, J. C., Dennis, M. L. (in press).
  Cannabis Youth Treatment (CYT) Overview and
  summary of preliminary findings. H. A. Liddle,
  C. L. Rowe (Eds.), Treating adolescent substance
  abuse State of the science . Cambridge, UK
  Cambridge University Press.
• Titus, J. C., Dennis, M. L., White, W. L., Scott,
  C. K., Funk, R. R. (2003). Gender differences
  in victimization severity and outcomes among
  adolescents treated for substance abuse. Journal
  of Child Maltreatment, 8, 19-35.
• Webb, C., Scudder, M., Kaminer, Y., Kadden, R.,
  Tawfik, Z. (2002). The MET/CBT 5 Supplement 7
  Sessions of Cognitive Behavioral Therapy (CBT 7)
  for adolescent cannabis users (Cannabis Youth
  Treatment (CYT) Manual Series, No. Volume 2).
  Rockville, MD Center for Substance Abuse
  Treatment, Substance Abuse and Mental Health
  Services Administration.