Transcript Insert Workshop Title

What works: Advances in
Adolescent Substance Abuse
Treatment and Research
Michael Dennis, Ph.D.
Chestnut Health Systems,
Bloomington, IL
Presentation for the SAMHSA National Policy Academy on Co-Occurring Mental and
Substance Abuse Disorders, April 14-16, 2004, Baltimore, MD. The opinions are those of the
author sdo not reflect official positions of the consortium or government . Available on line
at www.chestnut.org/li/posters.
Goals of this Presentation

Examine the prevalence, course, and
consequences of adolescent substance use

Summarize major trends in the adolescent
treatment system

Review the current knowledge base on
treatment effectiveness

Examine how characteristics and outcomes vary
by level of care.
Change in Past Month
Substance Use by Age
Source: Dennis (2002) and 1998 NHSDA.
Consequences of Substance Use
100
77
80
69
67
57
60
51
47
44
40
47
29
13
20
0
11
0 1
25
15
33
28
17
23
17
11
6
1
0
% 1+
% 1+
% Clinical
Symptom of Symptom of Behavior
Alcohol
Cannabis
Problems
Disorder
Disorder
% Physical
Fight
% Out of
School
% with 1+
ER in the
past year
No Past Year Alcohol or Marijuana Use
Weekly Alcohol Use
Weekly Marijuana Use (with Alcohol Use)
Source: Dennis, Godley and Titus (1999) and 1997 NHSDA.
% Any
Illegal
Activity
% 1+
Arrests
Source: Office of Applied Studies. (2000). 1998 NHSDA
Risk & Availability
Marijuana Use
Importance of Perceived Risk
The Adolescent Treatment System

Less than 1/10th of adolescents with substance dependence
problems receive treatment

Under 50% stay 6 weeks, 75% stay less than the 3 months
recommended by NIDA

From 1992 to 1998, admissions to treatment increased 53%
(96,787 to 147,899), but then leveled off in 1999 to 2002

From 1992 to 1998, admissions for treatment of primary,
secondary or tertiary marijuana use disorders increased
115% (51,081 to 109,875)
Source: Dennis, Dwaud-Noursi, Muck, & McDermeit, 2003; Hser et al., 2001; OAS, 2000
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
1992 admissions
Other*
(+154%)
Opiates
(+135%)
Inhalants
(-41%)
Cocaine
(+35%)
Hallucinogens
(-6%)
Stimulants
(+146%)
Alcohol
(+20%)
Marijuana
(+115%)
1998 admissions
Total
(+53%)
Annual Admissions .
Change in Adolescent Admissions (1992-1998)
* including tranquilizers, sedatives and o-t-c
Source:
Dennis, Dawud-Noursi, Muck & McDermeit, 2003
and 1992-1998 Treatment Episode Data Set (TEDS)
Patterns of Substance Use Problems
All Other
Patterns
16%
Alcohol
Only
9%
Marijuana
Only
23%
Alcohol
and
Marijuana
52%
Source:
Dennis, Dawud-Noursi, Muck & McDermeit, 2003
and 1998 Treatment Episode Data Set (TEDS)
Sources of Adolescent Referrals
Other
16%
Other
Health Care
Provider 5%
Other
Substance
Abuse
Treatment
Agency 5%
School/
Community
Agency 22%
Self/Family
17%
Source:
Criminal
Justice
System 44%
Dennis, Dawud-Noursi, Muck & McDermeit, 2003
and 1998 Treatment Episode Data Set (TEDS)
Level of Care at Admission
Long-Term
Residential
Short-Term
9%
Residential
6%
Detox. or
Hospital
5%
Intensive
Outpatient
11%
Source:
Dennis, Dawud-Noursi, Muck & McDermeit, 2003
and 1998 Treatment Episode Data Set (TEDS)
Outpatient
68%
Severity Varies by Level of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Weekly use at
intake
Dependence
First used Prior Treatment
under age 15
Outpatient (n=24704)
Intensive Outpatient (n=4024)
Detoxification or Hospital (n=2062)
Short Term Residential (n=2046)
Long Term Residential (n=3124)
Source:
Dennis, Dawud-Noursi, Muck & McDermeit, 2003
and 1998 Treatment Episode Data Set (TEDS)
Relatively Small And New Literature
Total
14
Epidemiology
4
Clinical
26
5
9
8
Pharmacology
3
0
24
16
5
5
40
8
10
15
20
1970-97 Publications
25
30
35
40
1998-2002 Publications
With over 65% of the studies first published in the past 5 years and over 3
dozen more currently in the field, we are entering a “renaissance of
knowledge” in this area.
Source: Dennis &, White (2003) at www.drugstrategies.org.
Key Lessons



Effectiveness was associated with therapies that:
– were manual-guided and 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
Interventions that are associated with no or minimal change in
substance use or symptoms:
– Passive referrals
– Educational units alone
– Probation services as usual
– Unstandardized outpatient services as usual
Interventions associated with deterioration:
– treatment of adolescents in “groups including one or more
highly deviant individuals” or that were mismanaged (but NOT
all groups)
– treatment of adolescents in adult units and/or with adult
models/materials (particularly outpatient)
Limitations of the 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 comorbidity
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
CSAT/
Other
NEW Adolescent Treatment Program
Grantees and Collaborators (80+ sites)
CSAT
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Other CSAT Grantees
Other Collaborators
RWJF Reclaiming Futures Program
RWJF Other RWJF Grantees
NIAAA/NIDA Other Grantees
Other Grants/Contracts
Source: www.chestnut.org/li/apss
Key Features






Pooled data over 3,500 and growing at over 1000/year
Diverse samples with low (under 15%) refusal and
attrition
Use a common standardized measure – Global Appraisal
of Individual Needs (GAIN) with explicit measures of
abuse, dependence, comorbidity, ASAM criteria and
services received
Manualized interventions, including several experiments
and replications of the same intervention across states
(publicly available at www.chestnut.org/li/apss )
High treatment completion and follow-up rates (generally
80-90%)
Over 3 dozen people doing research on scales, case mix,
matching rules, continuing care, and other topics.
Multiple Co-occurring Problems Are the
Norm and Increase
with
Level
Care
Co-occurring
Problems
by Levelof
of Care
100
88
80
80
60
78
68
70
65
56
44
52
47
43
35
40
21
52
25
44
36
21
20
0
Conduct
Disorder
Outpatient
ADHD
Major
Depressive
Disorder
Generalized
Anxiety
Disorder
Long Term Residential
Traumatic
Stress
Disorder
Any CoOccuring
Disorder
Short Term Residential
Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment
Study of Adolescents (PETS-A) studies
Severity is Related to Other Problems
100%
80%
71%
57%
60%
42%
37%
40%
30%
25%
22%
22%
20%
13%
5%
0%
Health Problem
Distress*
* p<.05
Acute Mental
Distress*
Acute
Traumatic
Distress*
Past Year Dependence (n=278)
Source: Tims et al 2002
Attention
Deficit
Hyperactivity
Disorder*
Conduct
Disorder*
Other (n=322)
High Rates of Victimization
Source: Dennis (2004)
Victimization is Related to Severity
Source: Titus, Dennis, et al., 2003
Interaction of Victimization and Treatment
Setting on Days of Marijuana Use
40
Both groups respond to
residential treatment
35
30
25
20
15
10
5 Traumatized groups
0 have higher severity
Pre
High trauma group
does not respond to OP
Post
OP - No/Low Victimization
OP - Acute Victimization
Resid - No/Low
Resid- Acute Victimization
Source: Funk, et al., 2003
Illegal Activity (not just possession)
Source: Adolescent Treatment Model (ATM) data
Change in Substance Frequency Index
by Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
Change in Substance Problem Index
by Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
Percent in Recovery (no past month use or
problems while living in the community)
\a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
Change in Emotional Problem Index
by Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
Change in Illegal Activity Index
by Level of Care\a
\a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term
Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient
intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.
Reducing Relapse After Residential Treatment
1.0
.9
Percent Remaining Abstinent
.8
.7
.6
.5
.4
Assertive
Continuing Care
.3
.2
Usual Continuing
Care
.1
0.0
0
Source: Godley et al 2002
90
180
270
Days to First Marijuana Use (p<.05)
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
Resources

Copy of these slides and handouts
–

Assessment Instruments
–
–

NCADI at www.health.org or www.chestnut.org/li/bookstore
CSAT CYT, ATM and other manuals at www.chestnut.org/li/apss/csat/protocols
Adolescent Treatment Programs and Studies
–
–
–
–

CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html
NIAAA Assessment Handbook,http://www.niaaa.nih.gov/publications/instable.htm
Adolescent Treatment Manuals
–
–

http://www.chestnut.org/LI/Posters/
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 <[email protected]> to be added to list server
Next conference is June 18, 2004, See website or E-mail Joan Unsicker
<[email protected]> for information about about meeting
References
Bukstein, O.G., & Kithas, J. (2002) Pharmacologic treatment of substance abuse disorders. In Rosenberg, D., Davanzo, P.,
Gershon, S. (Eds.), Pharmacotherapy for Child and Adolescent Psychiatric Disorders, Second Edition, Revised and Expanded.
NY, NY: Marcel Dekker, Inc.
Dennis, M.L., (2002). Treatment Research on Adolescents Drug and Alcohol Abuse: Despite Progress, Many Challenges
Remain. Connections, May, 1-2,7, and Data from the OAS 1999 National Household Survey on Drug Abuse
Dennis, M.L. (2004). Traumatic victimization among adolescents in substance abuse treatment: Time to stop ignoring the
elephant in our counseling rooms. Counselor, April, 36-40.
Dennis, M.L., & Adams, L. (2001). Bloomington Junior High School (BJHS) 2000 Youth Survey: Main Findings.
Bloomington, IL: Chestnut Health Systems
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., 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. Addiction, 95, S281S308.
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., Roebeck,
M. C., Godley, M. D., Hamilton, N., Liddle, H., Scott, C., & CYT Steering Committee. (in press). The Cannabis Youth Treatment
(CYT) experiment Rationale, study design, and analysis plans. Addiction, 97, 16-34..
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
References
Dennis, M.L. & White,M.A. (2003). The effectiveness of adolescent substance abuse treatment: a brief summary of studies
through 2002. Washington, DC: Drug Strategies. Retrived from www.drugstrategies.com .
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, 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, 2132.
Godley, M., Godley, S., Dennis, M., Funk, R. & Passetti, L. (2002). Findings from the Assertive Continuing Care
Experiment. Presentation at the American Public Health Association annual conference, Philadelphia, PA November 11, 2002.
Hser, Y., Grella, C. E., Hubbard, R. L., Hsieh, S. C., Fletcher, B. W., Brown, B. S., & Anglin, M. D. (2001). An evaluation of
drug treatments for adolescents in four U.S. cities. Archives of General Psychiatry, 58, 689-695.
Lewinsohn, P.M., Hops, H., Roberts, R.E., Seeley, J.R., Andrews, J.A. (1993). Adolescent psychopathology, I: prevalence and
incidence of depression and other DSM-III-R disorders in high school students. J Abn Psychol, 102, 133-144.
National Academy of Sciences (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research.
Washington, DC: National Academy Press.
Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD:
Substance Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics.
Office of Applied Studies (OAS) (1999). Treatment Episode Data Set (TEDS) 1992-1997: National admissions to substance
abuse treatment services. Rockville, MD: Author. [Available online at <http://www.icpsr.umich.edu/SAMHDA>.]
Office of Applied Studies (OAS) (2000). Treatment Episode Data Set (TEDS) 1993-1998: National admissions to substance
abuse treatment services. Rockville, MD: Author. [Available on line at <http://www.icpsr.umich.edu/SAMHDA.html>.]
Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD:
Substance Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics
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., 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.
Contact Information
Michael L. Dennis, Ph.D., Senior Research Psychologist
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]