Advances in Adolescent Substance Abuse Treatment and Research

1
Advances in Adolescent Substance AbuseTreatment
and Research

• Michael Dennis, Ph.D.
• Chestnut Health Systems,
• Bloomington, IL
• Presentation for the Adolescent Treatment
  Initiative, Concord, NH, April 20, 2005.
  Sponsored by New Futures. 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 and 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 [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org

2
Goals of this Presentation

• Examine the prevalence, course, and consequences
  of adolescent substance use and co-occurring
  disorders
• Examine the rates of use, substance use disorders
  (SUD) and unmet treatment needs in the US and NH
• Summarize major trends in the adolescent
  treatment system
• Review the current knowledge base on treatment
  effectiveness
• Examine the results of recent major studies
• Examine how characteristics vary by intensity of
  juvenile justice system involvement

3
Relationship between Past Month Substance Use
and Age
Source Dennis (2002) and 1998 NHSDA
4
Age of First Use Predicts Dependence an Average
of 22 years Later
Source Dennis, Babor, Roebuck Donaldson
(2002) and 1998 NHSDA
5
The Growing Incidence of Adolescent Marijuana
Use 1965-2002
Source OAS (2004). Results from the 2003
National Survey on Drug Use and Health National
Findings. Rockville, MD SAMHSA.
http//oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.p
df
6
Importance of Perceived Risk
Risk Availability
Marijuana Use
Source Office of Applied Studies. (2000). 1998
NHSDA
7
Actual Marijuana Risk

• From 1980 to 1997 the potency of marijuana in
  federal drug seizures increased three fold.
• The combination of alcohol and marijuana has
  become very common and appears to be synergistic
  and leads to much higher rates of problems than
  would be expected from either alone.
• Combined marijuana and alcohol users are 4 to 47
  times more likely than non-users to have a wide
  range of dependence, behavioral, school, health
  and legal problems.
• Marijuana and alcohol are the leading substances
  mentioned in arrests, emergency room admissions,
  autopsies, and treatment admissions.

8
Substance Use in the Community
Source Dennis and McGeary (1999) and 1997 NHSDA
9
Consequences of Substance Use
Source Dennis, Godley and Titus (1999) and 1997
NHSDA
10
Adolescents with Past Year Alcohol or Other Drug
(AOD) Abuse or Dependence
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
National8.92 NH12.21
11
Adolescents Needing But Not Receiving Treatment
for Alcohol Use
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
National5.55 NH8.24
12
Adolescents Needing But Not Receiving Treatment
for Illicit Drug Use
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
National5.14 NH6.99
13
Rates of Use in NH by Age
100
10
20
30
40
50
60
70
80
90
0
Any Alcohol Use
18
12
15
Age 12-17
Binge Alcohol Use
11
7
Any Past Month
Illicit Drug Use
72
50
31
Age 18-25
Any Past Month
30
Marijuana Use
11
Any Past Month
63
21
Illicit Beside Marijuana
7
Age 26
7
2
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA.
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
14
Rates of SUD and Unmet Tx Need in NH by Age
Abuse or Dependence
Unmet Treatment Need
10
15
20
25
30
35
0
5
12
Either
Age 12-17
8
Alcohol
7
Drug
31
Age 18-25
26
10
8
Age 26
7
1
Source D. Wright (2004). State Estimates of
Substance Use from the 2002 National Survey on
Drug Use and Health, Rockville, MD OAS, SAMHSA.
http//oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf
15
Adolescent Treatment Admissions have increased
by 50 over the past decade
Source Office of Applied Studies 1992- 2002
Treatment Episode Data Set (TEDS) http//www.samhs
a.gov/oas/dasis.htm
16
Change in Primary Substance
317 increase in marijuana
-50 decrease in alcohol
375 increase in stimulants
-21 decrease in cocaine
144 increase in opiates
Source OAS 2004, Treatment Episode Data Set
(TEDS) 1992-2002. Rockville, MD SAMHSA.
http//www.dasis.samhsa.gov/teds02/2002_teds_rpt.p
df
17
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.p
df
18
Primary Substance by Referral Source
More recent marijuana referrals driven more by JJ
Source OAS 2004, Treatment Episode Data Set
(TEDS) 1992-2002. Rockville, MD SAMHSA
http//www.dasis.samhsa.gov/teds02/2002_teds_rpt.p
df
19
Level of Care at Admission
Most Adolescents are treated in Outpatient
Settings
Source Dennis, Dawud-Noursi, Muck McDermeit,
2002 and 1998 Treatment Episode Data Set (TEDS)
20
Severity Varies by Level of Care
100
90
80
70
60
50
40
30
20
10
0
Weekly use at
Dependence
First used
Prior Treatment
intake
under age 15
Outpatient (n24704)
Intensive Outpatient (n4024)
Detoxification or Hospital (n2062)
Long Term Residential (n3124)
Short Term Residential (n2046)
Source Dennis, Dawud-Noursi, Muck McDermeit,
2002 and 1998 Treatment Episode Data Set
(TEDS)
21
Key Problems in the System

• Less than 1/10th of adolescents with substance
  dependence problems receive treatment
• Less than 50 stay 6 weeks
• Less than 75 stay the 3 months recommended by
  NIDA
• Under 25 in Residential Treatment successfully
  step down to outpatient care
• Little is known about the rate of initiation
  after detention
• The size of the NH system is actually coming out
  of a 7 year decline in admissions
• Source Dennis, Dawud-Noursi, Muck, McDermeit
  (Ives), 2002 Godley et al., 2002 Hser et al.,
  2001 OAS, 2000

22
NH is also a Heterogeneous Mix of Urban, Small
Urban Rural Systems

• 1,235,786 people in 9,345 square miles (137.8
  people per square mile or ppsm)
• Ranges from 18.8 ppsm in Coos County to 434.6
  ppsm in Hillsborough County
• Approximately 9 age 12-17, 4 age 18-20, 71 age
  21
• Source U.S. Census 2000

23
Pre-2002 Knowledge Base from 36 Studies

• 9 large multi-site longitudinal studies (ATM,
  DARP, TOPS, SROS, TCA, NTIES, DATOS-A, DOMS),
  including 1 large multi-site experiment (Cannabis
  Youth Treatment - CYT)
• 24 behavioral treatment studies (12-step,
  behavioral, family, other outpatient, inpatient,
  therapeutic communities, engagement, aftercare),
  including CYT and 1 pharmacology-behavioral (CBT)
  trial
• 8 pharmacology treatment studies (bupropion,
  disulfiram, fluoxetine, lithium, pemoline,
  sertaline) and 1 pharmacology-behavioral (CBT)
  trial
• Source Bukstein Kithas, 2002 Dennis White
  (2003), Lewinsohn et al. 1993 PNLDP, 2003

24
Key Lessons from Early Literature

• Assessment needs to be very concrete
• Multiple co-occurring problems are the norm in
  clinical samples of SUD adolescents (60-80
  external disorders, 25-60 mood disorders, 16-45
  anxiety disorders, 70-90 3 or more diagnoses)
• Adolescents are involved in multiple systems
  competing to control their behavior (e.g, family,
  peers, school, work, criminal justice, and
  controlled environments)
• Relapse is common in the first 3-12 months
• Recovery often takes multiple attempts and
  episodes of care that may take years
• Improvements generally come during active
  treatment and are sustained for 12 or more months
  
• Family therapies are associated with less initial
  change but more change post active treatment and
  less relapse

25
Interventions associated with reduced substance
use and problems

• 1 experimental and 3 non-experimental studies of
  12-step treatment (e.g., CD, Hazelden)
• 7 experimental studies of behavior therapies
  (e.g., ACRA, AGT, BTOS, CBT, MET, RP)
• 8 experimental studies of family therapy (CFT,
  FDE, FFT, FSN, FST, MDFT, MST, PBFT, TIPS)
• 6 longitudinal studies of existing outpatient
• 6 longitudinal studies of existing short term
  residential/inpatient
• 7 longitudinal studies of therapeutic communities
  (TC) and other forms of long term residential
  treatment (LTR)

Another 3 experimental studies have shown that
engagement and retention are associated with
several interventions (case management, stepping
down residential to OP, assertive aftercare)
26
Lessons from 9 Pharmacology Studies

• No controlled trials of medication for treating
  withdrawal, substitution therapy, blocking
  therapy, aversive therapy or management of
  cravings
• Though NIDAs Clinical Trials Network (CTN) and
  Australian researchers are currently studying the
  effects of Buprenorphine/Naloxone
• Most studies of other disorders exclude
  adolescents with substance use disorders
• Small (n of 8-25), short-term (4-12 weeks)
  studies suggest medication can be used to
  effectively treat several co-occurring problems
• Fluoxetine (Prozac) Sertaline (Zoloft) helped
  reduce depressive symptoms
• Lithium carbonate (Eskalith) reduced bipolar
  symptoms and positive urine rates
• Pemoline (Cylert) and Bupropion (Wellbutrin)
  reduced symptoms of ADHD

27
Effectiveness was also associated with therapies
that technologically were

• manual-guided
• had developmentally appropriate materials
• involved more quality assurance and clinical
  supervision
• achieved therapeutic alliance and early positive
  outcomes
• successfully engaged adolescents in aftercare,
  support groups, positive peer reference groups,
  more supportive recovery environments

28
Lessons about what did NOT work

• Interventions associated with No or Minimal
  Change
• Passive referrals
• Educational units alone
• Probation services as usual
• Early unstandardized outpatient services as usual

• Interventions associated with Deterioration
• treatment of adolescents in badly managed groups
  or groups including one or more highly deviant
  individuals (but NOT! all groups or any CD)
• treatment of adolescents in adult units and/or
  with adult models/materials (particularly
  outpatient)

29
Key Points that Have Been Contentious

• As other therapies have improved, there is no
  longer the clear advantage of family therapy
  found in early literature reviews
• While there have been concerns about the
  potential iatrogenic effects of group therapy,
  the rates do not appear to be appreciably
  different from individual or family therapy if it
  is done well (important since group tx typically
  costs less)
• Effectiveness was not consistently associated
  with the amount of therapy over a short period of
  time (6-12 weeks) but was related to longer term
  continuing care
• Over time, adolescents regularly cycle between
  use, treatment, incarceration and recovery
• Treatment primarily impacts the short term
  movement from use to non use in the community
• The long term effectiveness of therapy was
  dependent on changes in the long term recovery
  environment and social risk

30
Limitations of the Early Literature

• Small sample sizes (most under 50)
• High rates (30-50) of refusals by eligible
  people
• Unstandardized measures, no measures of abuse or
  dependence, no measures of co-morbidity, crime or
  violence (just arrest)
• Unstandardized and minimally-supervised therapies
  (making replication very difficult)
• Minimal information on services received
• High rates (20-50) of treatment dropout
• High rates of attrition from follow-up (25-54)
  leading to potentially large (unknown) bias

31
Studies are Improving!

• New studies are likely to have higher rates of
  participation (70-90), treatment completion
  (70-85), and successful follow-up (85-95)
• They are more likely to involve standardized
  assessments, manual-guided therapy, and better
  quality assurance/clinical supervision
• They have experimental design, multiple time
  points of assessment and follow-up lasting 1 or
  more years
• They include economic analysis of their costs,
  cost-effectiveness and benefit cost
• They have agreed to pool their data to facilitate
  further comparisons and secondary analysis

32
Studies by Date of First Publication
From 1998 to 2002 the number of adolescent
treatment studies doubled and has doubled again
in the past 2 years with twice this many
published in the past 2 years and over 100
adolescent treatment studies currently in the
field Source Dennis , White (2003) at
www.drugstrategies.org
33
Studies with Publications Currently Coming Out

• 1994-2000 NIDAs Drug Abuse Treatment Outcome
  Study of
• Adolescents (DATOS-A)
• 1995-1997 Drug Abuse Treatment Outcome Study
  (DOMS)
• 1997-2000 CSATs Cannabis Youth Treatment (CYT)
  experiments
• 1998-2003 NIAAA/CSATs 14 individual research
  grants
• 1998-2003 CSATs 10 Adolescent Treatment Models
  (ATM)
• 2000-2003 CSATs Persistent Effects of Treatment
  Study (PETS-A)
• 2002-2007 CSATs 12 Strengthening Communities for
  Youth (SCY)
• 2002-2007 RWJFs 10 Reclaiming Futures (RF)
  diversion projects
• 2002-2007 CSATs 12 Targeted Capacity Expansion
  TCE/HIV
• 2003-2009 NIDAs 12 individual research grants
• 2003-2006 CSATs 17 Adolescent Residential
  Treatment (ART)
• 2003-2008 NIDAs Criminal Justice Drug Abuse
  Treatment Study
• (CJ-DATS)
• 2003-2007 CSATs 36 Effective Adolescent
  Treatment (EAT)
• 2004-2007 NIAAA/CSATs study of diffusion of
  innovation

34
Adolescent Treatment Program GAIN Clinical
Collaborators
CSAT
Co-occurring Disorder Studies
Other Collaborators
Cannabis Youth Treatment (CYT)
RWJF Reclaiming Futures Program
Adolescent Treatment Model (ATM)
Other RWJF Grantees
Strengthening Communities for Youth (SCY)
NIAAA/NIDA Other Grantees
Adolescent Residential Treatment (ART)
Other Grants/Contracts
Effective Adolescent Treatment (EAT)
State, County, or Agency-wide systems (also
negotiating with 12 states/counties)
Young Offender Re-Entry Program (YORP)
Targeted Capacity Expansion (TCE) grants
Source www.chestnut.org/li/apss
35
Since 1997, the data has been pooled to create
one of the largest benchmark data sets in the
field
90,000
80,000
70,000
57,360
60,000
Cumulative GAIN Interviews (observations)
50,000
32,054
40,000
30,000
17,464
20,000
10,000
0
Prior to FY2003
FY2004
FY2005
FY2006
Half of all Adolescent Treatment Data
One of the Largest Data Sets in the Field with
1 year follow-up (2nd only to ASI)
Largest Combined Adolescent Data Set
36
(No Transcript)
37
Normal Adolescent Development

• Biological changes in the body, brain, and
  hormonal systems that continue into mid-to-late
  20s.
• Shift from concrete to abstract thinking.
• Improvements in the ability to link causes and
  consequences (particularly strings of events over
  time).
• Separation from a family-based identity and the
  development of peer- and individual-based
  identities.
• Increased focus on how one is perceived by peers.
• Increasing rates of sensation seeking/trying new
  things.
• Development of impulse control and coping skills.
• Concerns about avoiding emotional or physical
  violence.

38
Key Adaptation for Adolescents

• Examples need to be altered to relevant
  substances, situations, and triggers
• Consequences have to be altered to things of
  concern to adolescents
• Most adolescents do not recognize their substance
  use as a problem and are being mandated to
  treatment
• All materials need to be converted from abstract
  to concrete concepts

• Co-morbid problems (mental, trauma, legal) are
  the norm and often predate substance use
• Treatment has to take into account the multiple
  systems (family, school, welfare, criminal
  justice)
• Less control of life and recovery environment
• Less aftercare and social support
• Complicated staffing needs

39
Length of Stay Varies by Level of Care
Source Adolescent Treatment Model (ATM) Data
40
Adolescents often go through multiple levels of
care
Source Adolescent Treatment Model (ATM) Data
41
Program Evaluation Data
Completed follow-up calculated as 1
interviews over those due-done, with site varying
between 2-4 planned follow-up interviews. Of
those due and alive, 89 completed with 2
follow-ups, 88 completed 3 and 78 completed
4. Both LTR and STR include programs using CD
and therapeutic community models
42
Years of Use
Source Adolescent Treatment Model (ATM) data
43
Patterns of Weekly (13/90) Use
100
83
80
72
71
61
57
56
60
43
40
29
20
14
20
9
7
4
4
1
0
OP/IOP (n560)
LTR (n390)
STR (n594)
Weekly use of anything
Weekly Marijuana Use
Weekly Alcohol Use
Weekly Crack/Cocaine Use
Weekly Heroin/Opioid Use
Source Adolescent Treatment Model (ATM) data
44
Substance Use Severity
Source Adolescent Treatment Model (ATM) data
45
Change in Substance Frequency Indexby Level of
Care\a
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t
for time effect, \s for site effect, and \ts for
time x site effect.
46
Change in Substance Problem Indexby Level of
Care\a
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
47
Percent in Recovery (no past month use or
problems while living in the community)
\a Source Adolescent Treatment Model (ATM)
data Levels of cares coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t
for time effect, \s for site effect, and \ts for
time x site effect.
48
Multiple Co-occurring Problems Were the Norm and
Increased with Level of Care
100
88
80
78
80
70
68
65
56
60
52
52
47
44
44
43
35
36
40
25
21
21
20
0
Conduct
ADHD
Major
Generalized
Traumatic
Any Co-
Disorder
Depressive
Anxiety
Stress
Occurring
Disorder
Disorder
Disorder
Disorder
Outpatient
Long Term Residential
Short Term Residential
Source CSATs Cannabis Youth Treatment (CYT) and
Adolescent Treatment Model (ATM),
49
Change in Emotional Problem Indexby Level of
Care\a
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
50
Pattern of SA Outcomes is Related to the Pattern
of Psychiatric Multi-morbidity
2 Co-occurring 1 Co-occurring
No Co-occurring
Multi-morbid Adolescents start the highest,
change the most, and relapse the most
Number of Past Month Substance Problems
0
6
12
3
Months Post Intake (Residential only)
Source Shane et al 2003, PETSA data
51
High Rates of Victimization are the Norm
Source Adolescent Treatment Model (ATM) data
52
Victimization Is Related to Severity
0.4
0.3
0.2
0.1
Effect Size (f)
0
-0.1
-0.2
-0.3
-0.4
Substance
Substance
General Mental
Traumatic
General
Frequency
Problem Index
Distress Index
Stress Index
Conflict Tactic
Index
(SPI16 f.21)
(GMDI f.32)
(TSI f.25)
Index
(SFI6P f.13)
(GCTI f.20)
Low (n80)
Moderate (31)
High (n102)
Source Titus, Dennis, et al., 2003
53
Victimization Also Interacts with Level of Care
to Predict SA Outcomes
Outpatient
Residential
40
35
30
25
Marijuana Use (Days of 90)
20
15
10
5
0
Intake
6 Months
Intake
6 Months
OP -Acute
OP - Low/Cl.
Resid-Acute
Resid - Low/Cl.
Source Funk, et al., 2003
54
Broad Range of Past Year Illegal Activity
100
95
93
93
86
85
90
82
81
81
80
78
74
80
71
69
68
65
70
60
50
40
30
20
10
0
OP/IOP (n560)
LTR (n390)
STR (n594)
Any illegal activity
Property crimes
Interpersonal crimes
Drug related crimes
Acts of physical violence
Source Adolescent Treatment Model (ATM) data
55
Change in Illegal Activity Indexby Level of
Care\a
\a Source Adolescent Treatment Model (ATM)
data Levels of care coded as Long Term
Residential (LTR, n390), Short Term Residential
(STR, n594), Outpatient/Intensive and Outpatient
(OP/IOP, n560). T scores are normalized on the
ATM outpatient intake mean and standard
deviation. Significance (plt.05) marked as \t for
time effect, \s for site effect, and \ts for time
x site effect.
56
GAINs Crime and Violence Scale at Intake can
predict 30 Months Recidivism
100
90
80
70
No crime
Incarcerated
60
Substance Use only
50
Non-violent crime
Violent crime
40
X2(8)18.36, plt.05
30
20
10
0
Low (n150)
Moderate (n158)
High (n216)
Source White et al (2003), PETSA
57
Crime/Violence and Substance Problems Interact
to Predict Recidivism
Probability of 12 month recidivism
100
80
60
40
20
0
High
High
Mod.
Mod.
Low
Crime and
Low
Violence
Substance Problem Scale (Abuse/Dependence
symptoms)
Scale
Source Dennis et al 2004
58
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)

Source Godley et al 2002
59
Assertive Continuing Care (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)

60
Assertive Continuing Care (ACC)Hypotheses
Assertive Continuing Care
61
Usual Continuing Care (UCC) Expectation vs.
Performance
100
100
20
20
10
30
40
50
60
70
80
90
10
30
40
50
60
70
80
90
0
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
Expected
62
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
UCC
Source Godley et al 2002, forthcoming
63
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, forthcoming
64
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, forthcoming
65
Next Steps for ACC

• Preliminary findings and manual published, main
  findings under review
• Currently in use in eight clinical sites
• ACC 2 experiment is currently testing
• the ACC intervention model in a multi-site trial
  
• whether or not participants get contingency
  management (CM) alone or with ACC
• CM is targeted at reducing use and increasing
  prosocial activities

66
Secondary Analysis by Intensity of Juvenile
Justice System Involvement
Low
Hi
Severity
0
10
20
30
40
50
60
70
80
90
100
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
67
Intensity by Level of Care
Total
Step Down OP
Outpatient/IOP
Long Term Residential
Short Term Residential
0
10
20
30
40
50
60
70
80
90
100
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
68
Intensity by Demographics
100
90
80
70
60
50
40
30
20
10
0
Female
Caucasian
African
Hispanic
Native
Other
American
American
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
69
Intensity by Demographics (continued)
100
90
80
70
60
50
40
30
20
10
0
Age 11-15 Years
Age 15-17 Years
Age 18 Years
Single Parent
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
70
Intensity by Substance Use Disorder Diagnosis
100
90
80
70
60
50
40
30
20
10
0
Any Substance Disorder
Dependence
 Abuse
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data a\ Self report for past
year
71
Intensity by External Diagnoses
100
90
80
70
60
50
40
30
20
10
0
Any External
Conduct Disorder
ADHD
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
72
Intensity by Internal Diagnoses/Problems
100
90
80
70
60
50
40
30
20
10
0
Any Internal
   Major Depression
Suicide Ideation
   Generalized
Trauma Related
Anxiety
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data \b n1838 because some
sites did not ask trauma questions
73
Intensity by Pattern of Co-occurring Disorders
100
90
80
70
60
50
40
30
20
10
0
None
Internal Only
External Only
Both
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
74
Intensity by Other Common Problems
100
90
Focus of JJ Detention
80
70
60
50
40
30
20
10
0
    Any
High levels of
 Any Crime
High Crime/
    Homeless or
    High Health
Victimization
Victimization
Violence
Runaway
Problems
Detention 14 days (n433)
Probation/parole and urine monitoring 14 days
(n472)
Other detention, parole, or probation (n374)
Other current arrest or JJ status (n303)
Past arrest or JJ status (n170)
Past year illegal activity (n298)
Source CYT ATM Data
75
Concluding Comments

• We are entering a renaissance of new knowledge in
  this area, but are only reaching 1 of 10 in need
• Several interventions work, but 2/3 of the
  adolescents are still having problems 12 months
  later
• We need to move beyond focusing on minor
  variations in therapy (behavioral brand names)
  and acute episodes of care to focus on continuing
  care and a recovery management paradigm
• It is very difficult to predict exactly who will
  relapse so it is essential to conduct aftercare
  monitoring with all adolescents
• Juvenile justice referrals are a central factor
  in recent growth of the adolescent treatment
  system and the intensity of JJ involvement is
  correlated with clinical severity

76
Resources

• Copy of these slides and handouts
• http//www.chestnut.org/LI/Posters/
• 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
  
• Adolescent Treatment Manuals
• CSAT CYT, ATM, ACC and other manuals at
  www.chestnut.org/li/apss/csat/protocols or
  www.chestnut.org/li/bookstore
• SAMHSA at http//kap.samhsa.gov/products/manuals/c
  yt/index.htm or NCADI at www.health.org
• Adolescent Treatment Programs and Studies
• List of programs by state and summary of pre-2002
  studies at www.drugstrategies.com
• Cannabis Youth Treatment (CYT)
  www.chestnut.org/li/cyt
• Persistent Effects of Treatment Study of
  Adolescents (PETSA) www.samhsa.gov/centers/csat/
  csat.html (then select PETS from program
  resources)
• Adolescent Program Support Site (APSS)
  www.chestnut.org/li/apss
• Society for Adolescent Substance Abuse Treatment
  Effectiveness (SASATE)
• Website at www.chestnut.org/li/apss/sasate with
  bibliography
• E-mail Darren Fulmore ltdfulmore_at_mayatech.comgt to
  be added to list server
• Next conference is March 21-23, 2005, See website
  or E-mail Darren for information about meeting

77
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  Kaminer, Y. (2002). Subtypes for classifying
  adolescents with marijuana use disorders
  Construct validity and clinical implications.
  Addiction, 97(Suppl. 1), S58-S69.
• Buchan, B. J., Dennis, M. L., Tims, F. M.,
  Diamond, G. S. (2002). Cannabis use Consistency
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• Bukstein, O.G., Kithas, J. (2002) Pharmacologic
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• Dennis, M. L., Babor, T., Roebuck, M. C.,
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• Dennis, M. L., Godley, S. H., Diamond, G., Tims,
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• Dennis, M. L., Godley, S. and Titus, J. (1999).
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• Dennis, M. L., Perl, H. I., Huebner, R. B.,
  McLellan, A. T. (2000). Twenty-five strategies
  for improving the design, implementation and
  analysis of health services research related to
  alcohol and other drug abuse treatment.
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• Dennis, M. L. and McGeary, K. A. (1999).
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  need it now. TIE Communiqué
• (pp. 10-12). Rockville, MD Substance Abuse and
  Mental Health Services Administration, Center for
  Substance Abuse Treatment.

78
References - continued

• Dennis, M. L., Titus, J. C., Diamond, G.,
  Donaldson, J., Godley, S. H., Tims, F., Webb, C.,
  Kaminer, Y., Babor, T., Roebeck, M. C., Godley,
  M. D., Hamilton, N., Liddle, H., Scott, C., CYT
  Steering Committee. (2002). The Cannabis Youth
  Treatment (CYT) experiment Rationale, study
  design, and analysis plans. Addiction, 97,
  16-34..
• Dennis, M. L., Titus, J. C., White, M., Unsicker,
  J., Hodgkins, D. (2003). Global Appraisal of
  Individual Needs (GAIN) Administration guide for
  the GAIN and related measures. (Version 5 ed.).
  Bloomington, IL Chestnut Health Systems. Retrieve
  from http//www.chestnut.org/li/gain
• 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.
• 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.
• French, M.T., Roebuck, M.C., Dennis, M.L.,
  Diamond, G., Godley, S.H., Tims, F., Webb, C.,
  Herrell, J.M. (2002). The economic cost of
  outpatient marijuana treatment for adolescents
  Findings from a multisite experiment. Addiction,
  97, S84-S97.
• French, M. T., Roebuck, M. C., Dennis, M. L.,
  Diamond, G., Godley, S. H., Liddle, H. A., and
  Tims, F. M. (2003). Outpatient marijuana
  treatment for adolescents Economic evaluation of
  a multisite field experiment. Evaluation
  Review,27(4)421-459.
• Funk, R. R., McDermeit, 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.
• Godley, S. H., Dennis, M. L., Godley, M. D.,
  Funk, R. R. (2004). Thirty-month relapse
  trajectory cluster groups among adolescents
  discharged from outpatient treatment. Addiction,
  99 (s2), 129-139,
• Godley, M. D., Godley, S. H., Dennis, M. L.,
  Funk, R., Passetti, L. (2002). Preliminary
  outcomes from the assertive continuing care
  experiment for adolescents discharged from
  residential treatment. Journal of Substance Abuse
  Treatment, 23, 21-32.
• Godley, S. H., Jones, N., Funk, R., Ives, M., and
  Passetti, L. L. (2004). Comparing Outcomes of
  Best-Practice and Research-Based Outpatient
  Treatment Protocols for Adolescents. Journal of
  Psychoactive Drugs, 36, 35-48.
• Godley, M. D., Kahn, J. H., Dennis, M. L.,
  Godley, S. H., Funk, R. R. (2005). The
  stability and impact of environmental factors on
  substance use and problems after adolescent
  outpatient treatment. Psychology of Addictive
  Behaviors.

79
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• http//www.samhsa.gov/oas/dasis.htm
• Physician Leadership on National Drug Policy
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  (2003). Treatment outcomes among adolescents with
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• Tims, F. M., Dennis, M. L., Hamilton, N., Buchan,
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  adolescent cannabis abusers in outpatient
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• Titus, J. C., Dennis, M. L., White, W. L., Scott,
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  of Child Maltreatment, 8, 19-35.
• White, M. K., Funk, R., White, W., Dennis, M.
  (2003). Predicting violent behavior in adolescent
  cannabis users The GAIN-CVI. Offender Substance
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• White, M. K., White, W. L., Dennis, M. L.
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