How Symptom Severity Varies Depending on Age

1
How Symptom Severity Varies Depending on Age
the Substance of Abuse Michael Dennis Ya-Fen
Chan, Chestnut Health SystemsKendon Conrad,
University of Illinois at Chicago
American Evaluation Association 2006 Conference
Portland, OR, November 4, 2006 Multi-paper
Session 289 (Applications of the Rasch
Measurement Model in Evaluation ) to be held in
Salon Ballroom I on Thursday, November 2, 140
PM to 310 PM
2
Acknowledgement
This presentation was supported by analytic runs
provided Substance Abuse and Mental Health
Services Administration's (SAMHSA's) Center for
Substance Abuse Treatment (CSAT) under Contracts
207-98-7047, 277-00-6500, and 270-2003-00006
using data provided by the following grantees
CSAT (T100664, 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, TI11320, TI12541, TI00567)
NIAAA (R01 AA 10368) NIDA (R37 DA11323 R01 DA
018183 1R01 DA15523) Illinois Criminal Justice
Information Authority (95-DB-VX-0017) Illinois
Office of Alcoholism and Substance Abuse (PI
00567) Intervention Foundations Drug Outcome
Monitoring Study (DOMS), Robert Woods Johnson
Foundations Reclaiming Futures. Any opinions
about this data are those of the authors and do
not reflect official positions of the government
or individual grantees. 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 [phone],
fax [phone], e-Mail junsicker_at_chestnut.
org
3
Unresolved Questions from DSMs Substance Use
Disorder Criteria

• Do abuse and dependence symptoms vary along the
  same or different dimensions?
• Should the systems be weighted equally or
• Are physiological symptoms (tolerance and
  withdrawal) good markers of high severity?
• Are abuse symptoms good markers of low severity?
• Does the average and pattern of symptom severity
  vary by age substance? Are all relevant?
• Are diagnostic orphans (1-2 symptoms of
  dependence without abuse) similar to abuse or
  lower?
• Are multi-morbidity or age of on-set a good
  prognostic marker of severity?

For a more detailed list of issues, see Schuckit,
MA Saunders, JB (2006). The empirical basis of
substance use disorders diagnosis research
recommendations for the Diagnostic and
Statistical Manual of Mental Disorders, fifth
edition (DSM-V). Addiction, 101 (suppl 1.),
170-173.
4
Data Source and Methods

• Data from 2474 Adolescents, 344 Young Adults and
  661 Adults interviewed between 1998 and 2005 with
  the Global Appraisal of Individual Needs (GAIN
  Dennis et al 2003)
• Participants recruited at intake to Early
  Intervention, Outpatient, Intensive Outpatient,
  Short, Moderate Long term Residential,
  Corrections Based and Post Residential Outpatient
  Continuing Care as part of 72 local evaluations
  around the U.S. and pooled into a common data set
• Analysis here focuses on the GAIN Substance Use
  Disorder Scale (SUDS) with symptoms of dependence
  and abuse overall and by substance. The rating
  scale is 3past month, 2past 2-12 months, 1more
  than a year ago and 0never.
• Analyses done with a combination of Winsteps and
  Facets

5
Sample Characteristics
Young Adult
Adults
Adolescents
18-25
26
lt18 (n2474)
(n344)
(n661)
Male
74
58
47
Caucasian
48
54
29
African American
18
27
63
Hispanic
12
7
2
Average Age
15.6
20.2
37.3
Substance Disorder
85
82
90
Internal Disorder
53
62
67
External Disorder
63
45
37
Crime/Violence
64
51
34
Residential Tx
31
56
74
Current CJ/JJ invol.
69
74
45
Note all significant, p lt .01
6
Common Dimension of Dependence Abuse Symptom
Severity
Loss of Control
Desp.PH/MH
Despite Legal
Role Failure
Fights/troub.
Give up act.
Time Cons
Hazardous
Withdrawal
Tolerance
Can't stop
0.80
1st dimension explains 75 of variance (2nd
explains 1.2)
Average Item Severity (0.00)
0.60
0.40
0.20
Rasch Severity Measure
0.00
-0.20
-0.40
-0.60
7
Symptom Severity Vary By Age
Loss of Control
Desp.PH/MH
Despite Legal
Role Failure
Fights/troub.
Give up act.
Time Cons.
Hazardous
Withdrawal
Tolerance
Can't stop
1.8
26
1.6
Age
1.4
lt18
18-25
1.2
26
1
18-
0.8
18-
lt18
25
25
0.6
Rasch Severity Measure
26
18-
18-
lt18
25
0.4
26
25
26
lt18
lt18
lt18
lt18
18-
0.2
18-
26
18-
lt18
25
25
25
18-
18-
0
26
25
lt18
25
lt18
26
lt18
18-
26
-0.2
25
18-
-0.4
18-
26
25
26
25
26
-0.6
lt18
lt18
-0.8
26
-1
More likely to lead to fights among Adol/YA
Hazardous use more likely among Adol/YA
8
Average Severity by Age
1. Average goes up with age 2. Complete overlap
in range 3. Narrowing of distribution on
higher severity at older ages
2.00
1.50
1.00
0.50
0.00
-0.50
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
-4.00
Adolescent (lt18)
Young Adult (18-25)
Adult (26)
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Symptom Severity Vary by Substance
Loss of Control
Desp.PH/MH
Despite Legal
Role Failure
Fights/troub.
Time Cons.
Give up act.
Hazardous
Withdrawal
Tolerance
Can't stop
0.80
AVG (0.00)
CAN
AMP (0.89)
0.60
OPI (0.44)
COC (-0.22)
ALC (-0.44)
0.40
CAN (-0.67)
ALC
COC
COC
OPI
Rasch Severity Measure
CAN
0.20
ALC
ALC
CAN
ALC
AMP
AMP
ALC
AMP
AMP
CAN
COC
COC
CAN
AMP
ALC
OPI
OPI
OPI
OPI
CAN
0.00
AMP
CAN
AMP
COC
OPI
OPI
COC
OPI
OPI
CAN
OPI
AMP
AMP
COC
ALC
ALC
COC
ALC
AMP
CAN
COC
OPI
COC
COC
AMP
-0.20
ALC
ALC
CAN
-0.40
CAN
-0.60
10
Sx Severity by Drug (controlling for age)
Rasch Severity Measure
11
Lifetime Pattern of Substance Use Disorders
12
Past Month Status
13
Rasch Severity by Past Month Status
2.00
1.50
1.00
0.50
0.00
-0.50
Rasch Severity Measure
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
Dependence Only
Both Abuse and Dependence
None
Diagnostic Orphan in early remission
Diagnostic Orphan
Lifetime SUD in CE 45 days
Abuse Only
Lifetime SUD in early remission

14
Severity by Past Year Symptom Count
1. Better Gradation 2. Still a lot of overlap in
range
Rasch Severity Measure
15
Severity by Number of Past Year SUD Diagnoses
1. Better Gradation 2. Less overlap in range
2.00
1.50
1.00
0.50
0.00
Rasch Severity Measure
-0.50
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
-4.00
0
1
2
3
4
5
16
Severity by Weighted (past month2, past year1)
Number of Substance x SUD Symptoms
1. Better Gradation 2. Much less overlap in range
2.00
1.50
1.00
0.50
0.00
Rasch Severity Measure
-0.50
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
-4.00
0
1-4
5-8
9-12
13-16
17-20
21-24
25-30
31-40
41
17
Pathways to Recovery Study (Scott Dennis)

• Recruitment 1995 to 1997
• Sample 1,326 participants from sequential
  admissions to
• a stratified sample of 22 treatment units in 12
  
• facilities, administered by 10 agencies on
• Chicago's west side.
• Levels of Care Adult OP, IOP, MTP, HH, STR, LTR
• Instrument Augmented version of the Addiction
  Severity
• Index (A-ASI)
• Follow-up Of those alive and due, follow-up
  interviews were
• completed with 94 to 98 in annual interviews
  out to 8 years (going to 10 years) over 80
  completed within /- 1 week of target date.
• Source Dennis, M. L., Scott, C. K., Funk, R.,
  Foss, M. A. (2005). The duration and correlates
  of addiction and treatment careers. Journal of
  Substance Abuse Treatment, 28, S51-S62.

18
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
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
19
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
plt.05 (different from 21)
10
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
20
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
plt.05 (different from 20)
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
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Implications for SUD Concept

• Tolerance is not a good marker of high
  severity withdrawal (and substance induced
  health problems are)
• Abuse symptoms are consistent with the overall
  syndrome and represent moderate severity or
  other reasons to treat in the absence of the
  full blown syndrome
• Diagnostic orphans are lower severity, but
  relevant
• Pattern of symptoms varies by substance and age,
  but all symptoms are relevant
• Adolescents experienced the same range of
  symptoms, though they (and young adults) were
  particularly more likely to be involved with the
  law, use in hazardous situations, and to get into
  fights at lower severity
• Symptom and/or diagnostic counts appear to be
  more useful than the current DSM approach to
  categorizing severity
• Age of onset appears to be a good prognostic
  marker of severity