Transcript Addiction: what every judge should know

Addiction:
What Every Judge Should Know
Michael L. Dennis, Ph.D.
Chestnut Health Systems
Normal, IL
Presentation at “Addiction: What Every Judge Should Know” workshop,
March 5, 2009, Paul Brown Stadium, Cincinnati, Ohio. This presentation
was supported by funds from Ohio Supreme Court and Bureau of Justice
Assistance Edward Byrne Competitive National Interest Grant no 2008-DDBX-0710 and using data from NIDA grants no. R01 DA15523, R37-DA11323
and CSAT contract no. 270-07-0191. It is available electronically at
www.chestnut.org/li/posters . The opinions are those of the authors do not
reflect official positions of the government. Please address comments or
questions to the author at [email protected] or 309-820-3805.
Goals of this Presentation are to
1. Illustrate the Chronic Nature of Addiction and the
Correlates of Recovery
2. Demonstrate the Feasibility of Managing Addiction
Across Episodes of Treatment to Improve Long
Term Outcomes
3. Identify the Common Gaps in the Existing
Treatment System and What it Means to Move it
Toward Evidenced Based Practice
4. Demonstrate the Usefulness of Practice Based
Evidence to Inform Clinical Decision Making
About Placement and Treatment Planning
2
Illustrate the Chronic Nature of
Addiction and the
Correlates of Recovery
3
Severity of Past Year Substance Use/Disorders
(2002 U.S. Household Population age 12+= 235,143,246)
Dependence 5%
Abuse 4%
Regular AOD
Use 8%
Any Infrequent
Drug Use 4%
No Alcohol or
Drug Use
32%
Light Alcohol
Use Only 47%
Source: 2002 NSDUH; Dennis & Scott 2007
4
Problems Vary by Age
NSDUH Age Groups
100
90
80
Adolescent
Onset
Remission
Increasing
rate of nonusers
70
Severity Category
No Alcohol or Drug Use
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
0
Dependence
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
Source: 2002 NSDUH; Dennis & Scott 2007
5
Higher Severity is Associated with
Higher Annual Cost to Society Per Person
$4,000
Median (50th percentile)
$3,500
$3,000
Mean (95% CI)
$3,058
This includes people who are in
recovery, elderly, or do not use
because of health problems
$2,500
$2,000
$1,500
Higher
Costs
$1,613
$1,528
$1,309
$1,000
$948
$725
$1,078
$406
$500
$231
$231
$0
Dependence
Abuse
Regular
AOD
Use
Any
Infrequent
Drug Use
$0
$0
Light
Alcohol
Use Only
No
Alcohol or
Drug Use
Source: 2002 NSDUH; Dennis & Scott 2007
6
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 1989;4(4):371-377.
7
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 11:184-190, 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 14:169-177, 1993.
8
Serotonin Present in Cerebral Cortex Neurons
Reduced in response to excessive use
Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine
Still not back to
normal after 7 years
9
Adolescent Brain
Development Occurs from the
Inside to Out and
from Back to Front
pain
Photo courtesy of the NIDA Web site. From A
Slide Teaching Packet: The Brain and the
Actions of Cocaine, Opiates, and Marijuana.t
10
Overlap with Crime and Civil Issues





Committing property crime, drug related crimes,
gang related crimes, prostitution, and gambling to
trade or get the money for alcohol or other drugs
Committing more impulsive and/or violent acts
while under the influence of alcohol and other drugs
Crime levels peak between ages of 15-20 (periods or
increased stimulation and low impulse control in the
brain)
Adolescent crime is still the main predictor of adult
crime
Parent substance use is intertwined with child
maltreatment and neglect – which in turn is
associated with more use, mental health problems
and perpetration of violence on others
11
Substance Use Careers Last for Decades
1.0
.9
Median of 27
years from
first use to 1+
years
abstinence
.8
Cumulative Survival
.7
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
30
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
12
Substance Use Careers are
Longer the Younger the Age of First Use
1.0
.9
Age of
1st Use
Groups
.8
Cumulative Survival
.7
.6
.5
under 15*
.4
15-20*
.3
.2
21+
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
* p<.05
(different
from 21+)
13
Substance Use Careers are
Shorter the Sooner People Get to Treatment
1.0
.9
Year to
1st Tx
Groups
.8
Cumulative Survival
.7
20+
.6
.5
.4
.3
.2
10-19*
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
0-9*
* p<.05
(different
from 20+)14
Treatment Careers Last for Years
1.0
.9
.8
Median of 3
to 4 episodes
of treatment
over 9 years
Cumulative Survival
.7
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
Years from first Tx to 1+ years abstinence
Source: Dennis et al., 2005
15
Lifetime Mental Health Diagnosis and Remission
SUD Remission Rates
are BETTER than Most
Major DSM Diagnoses
100%
90%
89%
77%
80%
70%
89%
83%
66%
58%
60%
56% 48%
50%
46% 40% 39%
45%
50%
40%
20%
Lifetime Diagnosis
Past Year Remission
12%
11%
3%
Posttraumatic
Stress
4%
7%
Mood :
4%
18%
Anxiety :
9%
8%
Any Internalizing
Drug
0%
8%
8%
Attention Deficit
7%
Oppositional
Defiant
10%
Any
Externalizing
10%
15%
10%
Conduct
10%
8%
Intermittent
Explosive
13%
Alcohol
10%
15%
Any AOD
20%
31%
25%
30%
Remission Rate (% Remission / % Dependent)
Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication
16
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery (Adults)
Over half change
status annually
P not the same in
both directions
Incarcerated
(37% stable)
6%
7%
25%
30%
In the
Community
Using
(53% stable)
13%
8%
28%
In Recovery
(58% stable)
29%
4%
44%
31%
In Treatment
(21% stable)
Source: Scott, Dennis, & Foss (2005)
7%
Treatment is the
most likely path
to recovery
17
Predictors of Change Also Vary by Direction
Probability of Transitioning from Using to Abstinence
- mental distress (0.88)
+ older at first use (1.12)
-ASI legal composite (0.84)
+ homelessness (1.27)
+ # of sober friend (1.23)
+ per 8 weeks in treatment (1.14)
In the
Community
Using
(53% stable)
28%
In Recovery
(58% stable)
29%
Probability of Sustaining Abstinence
- times in treatment (0.83)
+ Female (1.72)
- homelessness (0.61)
+ ASI legal composite (1.19)
- number of arrests (0.89)
+ # of sober friend (1.22)
+ per 77 self help sessions (1.82)
Source: Scott, Dennis, & Foss (2005)
18
% Sustaining Abstinent through Year 8 .
Percent Sustaining Abstinence Through Year 8
by Duration of Abstinence at Year 7
100%
90%
80%
70%
60%
50%
40%
Even after 3 to 7 years of
abstinence about 14% relapse
It takes a year
of abstinence
before less than
half relapse
86%
86%
3 to 5 years
(n=59; OR=11.2)
5+ years
(n=96; OR=11.2)
66%
36%
30%
20%
10%
0%
1 to 12 months
(n=157; OR=1.0)
1 to 3 years
(n=138; OR=3.4)
Duration of Abstinence at Year 7
Source: Dennis, Foss & Scott (2007)
1.22
19
Other Aspects of Recovery
1-3 Years:
1-12 Months:
3-5 Years: 5-8 Years:
by Duration
of Abstinence
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%
% of Clean and
Sober Friens
80%
70%
% Days Worked
For Pay (of 22)
% Above
Poverty Line
60%
50%
40%
30%
20%
% Days of Psych
Prob (of 30 days)
10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)
Source: Dennis, Foss & Scott (2007)
% Days of Illegal
Activity (of 30 days)
20
Death Rate by Years of Abstinence
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
Users/ Early
Abstainers 2.87
times more
likely to die in
the next year
The Risk of Death
goes down with
years of sustained
abstinence
11.9%
7.1%
4.5%
Household
(OR=1.00)
It takes 4 or
more years of
abstinence for
risk to get
down to
community
levels
3.8%
Less than 1
(OR=2.87)
Source: Scott, Dennis, & Funk (2008)
1-3 Years
(OR=1.61)
4-8 Years
(OR=0.84)
21
These studies provide converging evidence
demonstrating that






Addiction is a brain disorder with the highest risk being
during the period of adolescent to young adult brain
development
Addiction is chronic in the sense that it often lasts for
years, the risk of relapse is high, and multiple
interventions are likely to be needed
Yet over two thirds of the people with addiction do
achieve recovery
Treatment increases the likelihood of transitioning from
use to recovery
Self help, peers and recovery environment help predict
who stays there
Recovery is broader than just abstinence
22
Demonstrate the Feasibility of
Managing Addiction Across
Episodes of Treatment to
Improve Long Term Outcomes
23
Lots of Geographic Variation in AOD Disorders
Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH
24
Cumulative Recovery Pattern at 30 months
5% Sustained
Recovery
37% Sustained
Problems
19% Intermittent,
currently in
recovery
39% Intermittent,
currently not in
recovery
The Majority of Adolescents
Cycle in and out of Recovery
Source: Dennis et al, forthcoming
25
Percent in Past Month Recovery*
Recovery* by Level of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
CC
better
OP &
Resid
Similar
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)
26
There Have Been Several Recent Reviews



Dennis & Scott (2007) review of evidenced related to
understanding and managing addiction as a chronic
condition
Marlowe (2008) and Bhati et al (2008) meta analyses
of Drug Treatment Court Effectiveness and CostEffectiveness
Mckay’s (in press) review of 22 experiments and
quasi experiments managing addiction over time
found improved outcomes in 38% of those focused on
less than 3 months, 44% on those that focused on 3 to
12 months and 100% of those that focused on more
than 12 months
Experiments with Continuing Care

Assertive Continuing Care 1 (ACC-2) experiment
with 183 adolescents discharged from residential
substance abuse treatment and followed for 9 months
in 1997-2004

Assertive Continuing Care 2 (ACC-2) experiment
with 342 adolescents discharged from residential
substance abuse treatment and followed for 12
months in 2005-2008

Assertive Outpatient Continuing Care Study
(AOCCS) experiment with 320 adolescents admitted
to outpatient substance abuse treatment and followed
for 12 months in 2003-2008
Time to Enter Continuing Care and Relapse
after Residential Treatment (Age 12-17)
100%
Percent of Clients
90%
80%
70%
Relapse
60%
50%
Cont.
Care
Admis.
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
29
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)
30
Assertive Continuing Care (ACC)
Hypotheses
Assertive
Continuin
g Care
General
Continuin
g Care
Adherence
Early
Abstinence
Sustained
Abstinence
Relative to UCC, ACC will increase General
Continuing Care Adherence (GCCA)
GCCA (whether due to UCC or ACC) will be
associated with higher rates of early abstinence
Early abstinence will be associated with higher
rates of long term abstinence.
31
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ACC Improved Adherence
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
UCC
ACC
* p<.05
32
GCCA Improved Early (0-3 mon.) Abstinence
100%
90%
80%
70%
60%
55%
50%
43%
36%
40%
30%
55%
38%
24%
20%
10%
0%
Any AOD (OR=2.16*)
Low (0-6/12) GCCA
Source: Godley et al 2002, 2007
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Marijuana (OR=1.98*)
* p<.05
33
Early (0-3 mon.) Abstinence Improved
Sustained (4-9 mon.) Abstinence
100%
90%
80%
73%
69%
70%
59%
60%
50%
40%
30%
20%
19%
22%
22%
10%
0%
Any AOD (OR=11.16*)
Alcohol (OR=5.47*)
Early(0-3 mon.) Relapse
Early (0-3 mon.) Abstainer
Source: Godley et al 2002, 2007
Marijuana (OR=11.15*)
* p<.05
34
Relating Standards of Proof to Science
Science
Law
Beyond a
Reasonable
Doubt
STRONGER
Clear and
Convincing
Evidence
Preponderance
of the Evidence
Probable
Cause
Reasonable
Suspicion
Source: Marlowe 2008
Meta Analyses of Experiments/ Quasi
Experiments (Summary v Predictive,
Specificity, Replicated, Consistency)
Dismantling/ Matching study (What worked for
whom)
Experimental Studies (Multi-site, Independent,
Replicated, Fidelity, Consistency)
Quasi-Experiments (Quality of Matching, Multisite, Independent, Replicated, Consistency)
Pre-Post (multiple waves), Expert Consensus
Correlation and Observational studies
Weak
Case Studies, Focus Groups
Levels of
Pre-data Theories, Logic Models
Expert
Anecdotes, Analogies
Testimony
35
Relating Standards of Proof to Science
Science
Law
Beyond a
Reasonable
Doubt
Probable
Cause
Reasonable
Suspicion
STRONGER
Clear and
Convincing
Evidence
Preponderance
of the Evidence
Meta
Analyses
of Experiments/
Adult
Drug Treatment
Courts 5Quasi
meta analyses of
Experiments
(Summary
Predictive,
76 studies found
crimevreduced
7-26% with
Specificity,
Consistency)
$1.74 Replicated,
to $6.32 return
on investment
Dismantling/ Matching study (What worked for
whom)
Family Drug Treatment Courts – one multisite
Experimental
Studies with
(Multi-site,
quasi experiment
positiveIndependent,
findings for
Replicated, Fidelity,
parentConsistency)
and child
Quasi-Experiments (Quality of Matching, MultiDWIIndependent,
Treatment Courts
– one quasi
experiment and
site,
Replicated,
Consistency)
five observational
with
effectConsensus
sizes of 0 to .45
Pre-Post
(multiplestudies
waves),
Expert
and one quasi
experiment (effect
size=.29 to .57)
Correlation
and Observational
studies
Case Studies, Focus Groups
Juvenile Drug Treatment Courts, Mental Health
Pre-data Theories, Logic Models
TreatmentAnalogies
Courts – multiple small studies with
Anecdotes,
mix of positive, null and negative findings36
Potential Cost Savings of Expanding Diversion
to Treatment Programs in Justice Settings

Currently treating about 55,000 people in these courts at
a cost of $515 million with an average return on
investment (ROI) of $2.14 per dollar

The ROI is higher (2.71) for those with more crime

It is estimated that there are at least twice as many
people in need of drug court as getting it

Investing the $1 billion to treat them would likely
produce a ROI of $2.17 billion to society
Source: Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of
Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban Institute.
37
Experiments with Recovery Management
Checkups to Manage Addiction Over Years




Early Re-Intervention (ERI) Experiment 1 –
448 adults entering treatment followed for 2-years
from 2000-2002
Early Re-Intervention (ERI) Experiment 2 –
446 adults entering treatment followed for 5-years
from 2004-2009
Women Offenders – 450 women coming out of
Cook County jail and followed for 3-years from
2008-2013
Early Re-Intervention for Adolescents (ERI-A)
– feasibility studies currently being conducted with
over longitudinal data on over 4,000 adolescents
38
Recovery Management Checkup (RMC)




Quarterly Screening to determining “Eligibility”
and “Need”
Linkage meeting/motivational interviewing to:
– provide personalized feedback to participants
about their substance use and related problems,
– help the participant recognize the problem and
consider returning to treatment,
– address existing barriers to treatment, and
– schedule an assessment.
Linkage assistance
– reminder calls and rescheduling
– Transportation and being escorted as needed
Treatment Engagement Specialist
39
ERI-2 Time to Treatment Re-Entry
100%
The size of the effect is
growing every quarter
Percent Readmitted 1+ Times
90%
80%
70%
RMC increases
the odds of
transitioning from
using to treatment
within a quarter
by 2.1
630-246 = -384 days
60%
55% ERI-2 RMC*
(n=221)
50%
40%
37% ERI-2 OM
(n=224)
30%
20%
10%
0%
0
90
180
270
360
450
540
*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001
Days to Re-Admission (from 3 month interview)
Source: Scott & Dennis (in press)
40
ERI-2: Impact on Outcomes at 45 Months
100%
90%
RMC Increased
Treatment Participation
80%
74%
71%
Percentage
70%
60%
More
days of
abstinent
61%
67%
55%
50%
OM
Fewer Seq.
Quarters
in Need
50%
41%
RMC
Less likely
to be in
Need at 45m
56%
47%
38%
40%
30%
20%
10%
0%
Re-entered
Treatment
(d=0.22)*
of 180 Days
of Treatment
(d= 0.26) *
Source: Scott & Dennis (in press)
of 1260 Days
Abstinent
(d= 0.26)*
of 14 Subsequent Still in need of
Quarters in Need Tx at Mon 45
(d= -0.32)*
(d= -0.22) *
* p<.05
41
ERI 2: Average Quarterly Transitions over 3
years
34% Changed
Status in an
Average Quarter
Incarcerated
(56% stable)
4%
3%
13%
23%
In the
Community
Using
(75% stable)
10%
8%
10%
In Recovery
(58% stable)
24%
7%
25%
35%
In Treatment
(32% stable)
6%
Again the
Probability of
Entering Recovery
is Higher from
Treatment
Source: Riley, Scott & Dennis, 2008 42
ERI 2: Average Quarterly Transitions
over 3 years
Transition Tx to Recovery (vs. relapse)
- Freq. of Use (0.01) + Wks Self Help (1.39)
-Tx Resistance (0.79) +Self Help Act. (1.31)
In the
Community
Using
(75% stable)
10%
Transition to Tx (vs use)
- Tx Resistance (0.93)
+ Freq. of Use (25.30)
+ Desire for Help (1.23)
+ Wks of Self Help (1.51)
+ Self Help Act. (1.37)
+ Prior Wks of Tx (1.07)
+ RMC (2.08)
In Recovery
(58% stable)
25%
35%
In Treatment
(32% stable)
Source: Riley, Scott & Dennis, 2008 43
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
P not the same in
both directions
Incarcerated
(46% stable)
5%
10%
20%
In the
Community
Using
(75% stable)
7%
Avg of 39% change
status each quarter
12%
3%
More likely than
adults to be diverted
to treatment
(OR=4.0)
24%
In Recovery
(62% stable)
27%
7%
19%
26%
In Treatment
(48% stable)
More likely than adults to stay 90
Source: Dennis et al 2007. 2006 CSAT AT data set
days in treatment (OR=1.7)
7%
Treatment is the
most likely path
to recovery
44
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
Community
Using
(75% stable)
12%
In Recovery
(62% stable)
27%
Probability of Sustaining Recovery vs. Relapsing (+ 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,
45
drugs, fighting, or involved in illegal activity.
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: Dennis et al 2007. 2006 CSAT AT data set
46
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
Community
Using
(75% stable)
In Recovery
(62% stable)
26%
19%
In Treatment
(48 v 35% stable)
Source: Dennis et al 2007. 2006 CSAT AT data set
* 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.
47
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
Incarcerated
(46% stable)
20%
10%
In the
Community
Using
(75% stable)
In Recovery
(62% stable)
Probability of Going to Using vs. Early “Recovery” (+ good)
+ Recovery Environment (r)* (3.33)
* 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: Dennis et al 2007. 2006 CSAT AT data set
48
These studies provide converging evidence
demonstrating that





More assertive continuing care can increase adherence
with continuing care expectations
A growing range of drug treatment courts are being
found effective and cost effective
Recovery management checkups can identify people
who have relapsed and get them back to treatment
faster
That doing each improves short and long term
outcomes
That it appears feasible to extend recovery
management checkups to adolescents, but that there is
a need to focus even more on recovery environment
and peer groups
49
Identify the Common Gaps
in the Existing Treatment System
and What it Means to Move it
Toward Evidenced Based Practice
50
Substance Use Disorder &
Treatment Participation Rates by Age
Less than 1 in 17
adolescents, 1 in 22 young
adults, and 1 in 12 adults
0
5
10
15
20
25
5.4
5.9
12 to 17
Drug Disorder
8.9
Alcohol Disorder
Any Disorder
8.1
17.3
18 to 25
21.2
Drug Treatment
Alcohol Treatment
1.8
6.2
7.3
26+
0
5
Any Treatment
10
15
Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH
20
25
51
Median Length of Stay in Days
The Majority Stay in Tx Less than 90 days
90
60
Half are gone within 8
weeks, less than 25%
stay the 90 days
recommended by NIDA
researchers
52
42
33
30
20
0
Outpatient
Intensive
Outpatient
Short Term
Residential
Long Term
Residential
Level of Care
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/teds02/2002_teds_rpt_d.pdf .
52
Less Than Half Are Positively Discharged
100%
90%
Other
Discharge Status
80%
70%
Terminated
60%
Dropped out
50%
40%
Completed
30%
20%
Transferred
10%
0%
Outpatient
Intensive Short Term Long Term
Outpatient Residential Residential
Less than 10%
are transferred
Level of Care
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/teds02/2002_teds_rpt_d.pdf .
53
Programs often LACK Standardized
Assessment for…






Substance use disorders (e.g., abuse, dependence,
withdrawal), readiness for change, relapse potential
and recovery environment
Common mental health disorders (e.g., conduct,
attention deficit-hyperactivity, depression, anxiety,
trauma, self-mutilation and suicidality)
Crime and violence (e.g., inter-personal violence, drug
related crime, property crime, violent crime)
HIV risk behaviors (needle use, sexual risk,
victimization)
Child maltreatment (physical, sexual, emotional)
Recovery environment and peer risk
54
Other Challenges in Substance Abuse
Treatment Workforce and Organizations

High turnover workforce with variable education
background related to diagnosis, placement and
treatment planning.

Heterogeneous needs and severity characterized by
multiple problems, chronic relapse, and multiple
episodes of care

Lack of access to or use of data at the program
level to guide immediate clinical decisions, billing
and program planning

Missing or misrepresented data that needs to be
minimized and incorporated into interpretations
55
So what does it mean to move the field
towards Evidence Based Practice (EBP)?




Introducing explicit interventions that have worked well
on average and have explicit implementation/ quality
assurance protocols at the program and individual level
Collecting practice based evidence to evaluate
performance and outcomes for the program, protocol or
staff over time, or relative to other interventions
Introducing reliable and valid assessment that can be
used immediately to guide clinical judgments about
diagnosis/severity, placement, treatment planning,
implementation and the response to treatment
Pooling the above to drive needs assessment,
performance monitoring and long term program
evaluation and planning
56
What is Treatment?











Motivational Interviewing and other protocols to help them
understand how their problems are related to their substance
use and that they are solvable
Residential, IOP and other types of structured environments to
reduce short term risk of relapse
Detoxification and medication to reduce pain/risk of
withdrawal and relapse, including tobacco cessation
Evaluation of antecedents and consequences of use
Community Reinforcement Approaches (CRA)
Relapse Prevention Planning
Cognitive Behavioral Therapy (CBT)
Proactive urine monitoring
Motivational Incentives / Contingency Management
Access to communities of recovery for long term support,
including 12-step, recovery coaches, recovery schools,
recovery housing, workplace programs
Continuing care, phases for multiple admission
57
Other Specific Services that are Screened for
and Needed by People in Treatment:








Tobacco cessation
HIV Intervention to reduce high risk pattern of
behavior (sexual, violence, & needle use)
Anger Management
Psychiatric services related to depression, anxiety,
ADHD/Impulse control, conduct disorder/ ASPD/
BPD, Gambling
Trauma, suicide ideation, and para-suicidal behavior
Child maltreatment and domestic violence
interventions (not just reporting protocols)
Family, school and work problems
Case management and work across multiple systems
of care and time
58
Components of Comprehensive Drug
Addiction Treatment Recommended by NIDA
www.drugabuse.gov
59
Two Key Resources Available from NIDA
(http://www.drugabuse.gov )
60
Major Predictors of Bigger Effects
1.
A strong intervention protocol based on
prior evidence
2.
Quality assurance to ensure protocol
adherence and project implementation
3.
Proactive case supervision of individual
4.
Triage to focus on the highest severity
subgroup
61
Impact of the numbers of these Favorable
features on Recidivism in 509 Juvenile
Justice Studies in Lipsey Meta Analysis
Average
Practice
Source: Adapted from Lipsey, 1997, 2005
The more
features, the
lower the
recidivism
62
Cognitive Behavioral Therapy (CBT) Interventions
that Typically do Better than Usual Practice in
Reducing Juvenile 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
63
Impact of Simple On-site Urine Protocol
with Feedback On False Negative Urines
25%
Off Site
19%
20%
15%
15%
On-Site
With
Immediate
Feedback
10%
5%
On-site
Urine
Feedback
Protocol
associated
with Lower
False
Negatives
(19 v 3%)
5%
3%
0%
Mon 12
Source: Scott & Dennis (in press)
Mon 24
64
Implementation is Essential
(Reduction in Recidivism from .50 Control Group Rate)
The best is to
have a strong
program
implemented
well
Thus one should optimally pick the
strongest intervention that one can
implement well
Source: Adapted from Lipsey, 1997, 2005
The effect of a well
implemented weak program is
as big as a strong program
implemented poorly
65
Range of Effect Sizes (d) of MET/CBT for
Change in Days of Abstinence by Site
1.40
1.20
6 programs
completely
above
Experiment
Replication Sites
Averaged Better than
Experiment
Cohen’s d
1.00
1.40
1.20
1.00
0.80
0.80
0.60
0.60
0.40
0.40
0.20
0.20
75% above median
of Experiment
0.00
4 Experiment Sites (f=0.39)
(median within site d=0.29)
Source: Dennis, Ives, & Muck, 2008
0.00
36 Replication Sites (f=0.21)
(median within site d=0.49)
66
Number of Problems by Level of Care (Triage)
100%
90%
0 to 1
80%
2 to 4
70%
60%
5 or more
50%
40%
67%
30%
20%
50%
78%
55%
39%
10%
0%
Outpatient
(OR=1)
Intensive
Outpatient
(OR=1.6)
Long Term
Residential
(OR=1.9)
Source: Dennis et al 2009; CSAT 2007 Adolescent
Treatment Outcome Data Set (n=12,824)
Med. Term
Residential
(OR=3.2)
*
Short Term
Residential
(OR=5.5)
Clients entering
Short Term
Residential
(usually dual
diagnosis) have
5.5 times higher
odds of having 5+
major problems*
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
67
No. of Problems* by Severity of Victimization
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None
One
Two
Three
Four
Five+
70%
45%
Those with
15%
high lifetime
levels of
victimization
Low
Mod.
High
have 13 times
(OR 1.0)
(OR=4.6) (OR=13.2)
higher odds of
having 5+
Severity of Victimization
major
* (Alcohol, cannabis, or other drug disorder,
Source: Dennis et al 2009; CSAT 2007 Adolescent
problems*
depression, anxiety, trauma, suicide, ADHD,
CD,
Treatment Outcome Data Set (n=12,824)
victimization, violence/ illegal activity)
68
Victimization and Level of Care
Interact to Predict Outcomes
Marijuana Use (Days of 90)
40
CHS Outpatient
CHS Residential
Traumatized groups have
35 higher severity
30
25
20
15
10
High trauma group does
not respond to CHS OP
5
0
Intake
OP -High
6 Months
OP - Low/Mod
Source: Funk, et al., 2003
Intake
Resid-High
Both groups respond to
residential treatment
6 Months
Resid - Low/Mod.
69
Crime/Violence and Substance Problems Interact
to Predict Any Recidivism
Crime/
Violence
predicted
recidivism
80%
60%
40%
20%
Crime and
Violence
Scale
0%
Knowing both was the
best predictor
Source: CYT & ATM Data
12 month recidivism
100%
Substance
Problem
Scale
Substance Problem
Severity predicted
recidivism
70
100%
80%
Crime/
Violence
predicted
violent
recidivism
60%
40%
20%
Crime and
Violence
Scale
0%
Knowing both was the
best predictor
Source: CYT & ATM Data
12 month recidivism
To violent crime or arrest
Crime/Violence and Substance Problems Interact
Differently to Predict Recidivism to Violent Crime
Substance
Problem
Scale
(Intake) Substance
Problem Severity did
not predict violent
recidivism
71
Problems With the Treatment System







Only 5-10% of those with abuse/dependence are
entering treatment
Less than 75% stay the 90 days recommended by
NIDA (half less than 50 days)
Less than half are positively discharge
Less than 10% leaving higher levels of care are
transferred to outpatient continuing care
The majority of programs do NOT use standardized
assessment, evidenced based treatment, track the
clinical fidelity of the treatment they provide or
monitor their own performance in terms of client
outcomes
Evidenced based practices can improve outcomes
We can learn from practice based evidence
72
Demonstrate the Usefulness of
Practice Based Evidence to Inform
Clinical Decision Making About
Placement and Treatment Planning
73
No or Inconsistent Use of Placement Criteria

Average staff education is an Associate Degree and
stay less than 2 years

In practice, programs primarily refer people to the
limited range of services they have readily available.

Knowing nothing about the person other than what
door they walked through we can correctly predict
75% (kappa=.51) of the adolescent level of care
placements.

The American Society for Addiction Medicine
(ASAM) has tried to recommend placement rules for
deciding what level of care an adolescent should
receive based on expert opinion, but run into many
problems.
74
Examples of problems with placement
(even with ASAM)

difficulty synthesizing multiple pieces of information

inconsistencies between competing rules

the lack of the full continuum of care or specific
services to refer people to

having to negotiate with the participant, families and
funders over what they will do or pay for

there is virtually no actual data on the expected
outcomes by level of care to inform decision making
related to placement
75
CSAT Adolescent Treatment GAIN Data
from 203 level of care x site combinations
Levels of Care
Long-term Residential
Moderate-Term Residential
Short-Term Residential
Source: Dennis, Funk & Hanes-Stevens, 2008
Outpatient Continuing Care
Intensive Outpatient
Outpatient
Early Intervention
General Group Home
Corrections
Other
76
Global Appraisal of Individual Needs (GAIN)




The GAIN is a family of assessment tools ranging from
a 5 minute screener to 20 minute quick assessment to a
1-2 hour comprehensive bio-psychosocial
The GAIN Recommendation and Referral Summary
(GRRS) is a 6 to 8 page narrative report designed to
help clinical staff generate diagnostic impressions,
preliminary treatment planning recommendations, and
level of care placement recommendations.
For each ASAM dimension, the GRRS includes
narrative summaries of the client’s problems, treatment
history, and treatment planning recommendations
This information can also be used to group individuals
with similar presenting profiles
77
Ratings of Problem Severity (x-axis) by Treatment
Utilization (y-axis) by Population Size (circle size)
Utilization
Average Current Treatment
.
1.00
F. HiHi (CC)
12%
0.80
0.60
0.40
B
Low- Mod
0.20
0.00
C
Mod-Mod
20%
A
Low-Low
D
Hi-Low
8%
12%
-0.20
-0.20
G. Hi-Mod
(Env Sx/
PH Tx)
9%
E
HiMod
14%
14%
H. Hi-Hi
(Intx Sx;
PH/MH Tx)
12%
0.00
0.20
0.40
0.60
0.80
1.00
Average Current Problem Severity
78
While over 50% go to outpatient in 7 of 8 clusters,
there are a range of placements in each cluster
0%
20%
40%
60%
80%
100%
A Low-Low
B Low-Mod
C Mod-Mod
D Hi-Low
E Hi-Mod
F Hi-Hi (CC)
G Hi-Mod (E/P)
H Hi-Hi (I/P/M)
Outpatient (OP)
Outpatient Continuing Care (OPCC)
Long Term Residential (LTR)
Intensive Outpatient (IOP)
Short Term Residential (STR)
79
Variance Explained in NOMS Outcomes
Percent of Variance Explained
0%
5%
10%
15%
20%
25%
24%
No AOD related Problem
11%
No Health Problems
25%
No Mental Health Problems
15%
No Illegal Activity
33%
No JJ System Involve.
26%
Living in Community
18%
No Family Prob.
14%
Vocationally Engaged
8%
Count of above
\1
Past month
\2
35%
26%
No AOD Use
Social Support
30%
Past 90 days *All statistically Significant
24%
80
Predicted Count of Positive Outcomes by Level
Predicted Count of Positive Outcomes by Level of Care:
of Care: Cluster
A
Low
Low
(n=1,025)
Cluster A Low - Low (n=1,025)
10
10
9
9
8
8
7
7
6
6
5
5
4
Person “A” does
better in Outpatient
3
Person “B” does
better in Higher
Levels of Care
2
4
3
2
Outpatient
Higher LOC
81
Best Level of Care*:
Cluster A Low -Best
Low
(n=1,025)
of Care*:
Level
Cluster A Low - Low (n=1,025)
120%
% Best Predicted Outcomes
99.6%
100%
80%
60%
40%
20%
0.4%
0%
Outpatient
Higher LOC
* Based on Maximum Predicted Count of Positive Outcomes
82
A Low-Low (n=1456): Top 10 Tx Needs
79% - Not close to anyone in recovery, assign a recovery coach
73% - Assign to relapse prevention
52% - Discuss recent school problems and how they can be
resolved
50% - Coordinating care with juvenile justice system
50% - HIV Intervention to reduce high risk pattern of sexual
behavior
41% - Increase structure to reduce recovery environment risk
33% - Discussing the consequences of behavior control problems,
the plan to change, and possible referrals to help.
31% - Referral for tobacco cessation
30% - Review prior treatment experiences to determine what did
and not work
29% - Develop plan for reduction of family fighting
83
Best Level of Care*:
of Care*:
Best Level
Cluster C Mod-Mod
(n=1209)
Cluster C Mod-Mod (n=1209)
90%
% Best Predicted Outcomes
80%
70%
60%
50%
40%
38.6%
30.2%
30%
23.6%
20%
7.6%
10%
0%
Outpatient
IOP
OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
84
C Mod-Mod (n=1734): Top 10 Tx Needs
93% - Increase structure and/or residential treatment to reduce
recovery environment risk
91% - Discussing the consequences of behavior control problems,
the plan to change, and possible referrals to help.
85% - Referral for mental health treatment
85% - Refer to anger management intervention
84% - Follow agency protocol related to child maltreatment
reporting; Refer for trauma related intervention
82% - Review prior treatment experiences to determine what did
and not work
76% - HIV Intervention to reduce high risk pattern of sexual
behavior
72% - Discuss recent school problems and how they can be
resolved
70% - Coordinating care with juvenile justice system
62% - Not close to anyone in recovery, assign a recovery coach
85
Best Level of Care*:
Level of Care*:
Cluster F Hi-HiBest
(CC)
(n=968)
Cluster F Hi-Hi (CC) (n=968)
90%
81.5%
% Best Predicted Outcomes
80%
70%
60%
50%
40%
30%
20%
10%
9.9%
8.6%
0.0%
0%
Outpatient
IOP
OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
86
F Hi-Hi (CC) (n=1402): Top 10 Tx Needs
98% - Refer to continuing care following discharge from controlled
environment
97% - Referral for mental health treatment
94% - Develop plan for obtaining stable housing
87% - Increase structure and/or residential treatment to reduce
recovery environment risk
85% - Coordinating care with juvenile justice system
81% - HIV Intervention to reduce high risk pattern of sexual
behavior
78% - Develop community re-entry plan
78% - Follow agency protocol related to child maltreatment
reporting; Refer for trauma related intervention
72% - Discussing the consequences of behavior control problems,
the plan to change, and possible referrals to help.
64% - Refer to anger management intervention
87
Best Level of Care*:
Cluster G Hi-Mod
(n=749)
Level of Care*:
Best(Env/PH)
Cluster G Hi-Mod (Env/PH) (n=749)
100%
94.1%
90%
80%
70%
60%
50%
40%
30%
20%
10%
5.9%
0.0%
0%
Outpatient
IOP/OPCC
Residential
* Based on Maximum Predicted Count of Positive Outcomes
88
G Hi-Mod (Env/PH) (n=1038): Top 10 Tx Needs
100%-Consider need for detoxification or withdrawal services
100% Consider medication to reduce non-opioid withdrawal and
relapse
99% - Review participation (attendance, motivation, participation,
etc.) of client, participation in family therapy, day treatment
or other interventions to increase structure.
93% - Increase structure and/or residential treatment to reduce
recovery environment risk
91% - Referral for mental health treatment
79% - HIV Intervention to reduce high risk pattern of sexual
behavior
79% - Referral for tobacco cessation
79% - Discussing the consequences of behavior control problems,
the plan to change, and possible referrals to help.
74% - Review prior treatment experiences to determine what did
and not work
74% - Follow agency protocol related to child maltreatment
reporting; Refer for trauma related intervention
89
Summary of Best Level Of Care Based on
Cluster and Expected Outcome
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Higher than OP
Residential
IOP/OPCC
OPCC
IOP
OP
Cluster A
Low - Low
(n=1025)
Cluster B
Low - Mod
(n=1654)
Cluster C
Mod-Mod
(n=1209)
Cluster D
Hi-Low
(n=687)
Cluster E
Hi-Mod
(n=1190)
14.1%
7.6%
38.3%
27.9%
88.3% *
0.4%
10.5%
75.1%*
30.2%
23.6%
38.6%
Cluster G Cluster H
Cluster F
Hi-Mod
Hi-Hi
Hi-Hi (CC)
(Env/PH) (Intx/PH/MH (n=968)
0.4%
99.6%*
33.8%
1.1%
0.0%
10.6%
94.1% *
0.0%
5.9%
17.2%
8.6%
78.2% *
4.6%
0.0%
81.5% *
9.9%
0.0% 90
Change in Days Abstinent (while in
community) by Level of Care and Gender
90
80
Days of Abstinence
70
60
50
40
30
Female - OP (d=0.43)
20
Males - OP (d=0.33)
Female - Resid (d=0.82)
10
Males -Res (d=0.74)
0
Intake
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
Last Followup
91
MALES: Change in Days Abstinent in
Community by type of Outpatient Approach
90
MST (d=0.87) (n=25)
Days of abstinence in Community
80
Other Mot. Interv (d=0.79) (n=130)
ACRA/ACC (d=0.53) (n=460)
70
FSN (d=0.48) (n=337)
Other (d=0.43) (n=482)
60
EMPACT (d=0.4) (n=102)
50
METCBT5 (d=0.33) (n=3368)
Total (d=0.33) (n=6272)
40
Other CBT (d=0.32) (n=150)
Seven Challenges (d=0.27) (n=93)
30
METCBT12 (d=0.2) (n=506)
20
EPOCH (d=0.18) (n=146)
CHS OP (d=0.15) (n=281)
10
MDFT (d=0.07) (n=99)
METCBT7 (d=-0.03) (n=93)
0
Intake
Last Follow-up
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
92
FEMALES: Change in Days Abstinent in
Community by type of Outpatient Approach
90
Other Mot. Interv (d=0.87) (n=50)
MST (d=0.86) (n=11)
80
Days of abstinence in Community
EMPACT (d=0.62) (n=31)
70
Other (d=0.52) (n=120)
CHS OP (d=0.48) (n=97)
60
METCBT12 (d=0.48) (n=174)
Seven Challenges (d=0.44) (n=51)
50
Total (d=0.42) (n=2339)
40
FSN (d=0.41) (n=96)
Other CBT (d=0.41) (n=35)
30
METCBT5 (d=0.4) (n=1491)
METCBT7 (d=0.38) (n=40)
20
MDFT (d=0.36) (n=28)
10
ACRA/ACC (d=0.35) (n=86)
EPOCH (d=0.02) (n=29)
0
Intake
Last Follow-up
Source: CSAT 2007 AT Outcome Data Set (n=11,013)
93
These analyses of Practice Based Evidence

Suggest that it is feasible to group people by their
presenting needs and predict outcomes

This can be done by level of care or by type of
evidenced based protocol within level of care or a
subgroup (e.g., gender)

Making this data available to patients, families, clinical
staff and the courts have the potential to improve
patient outcome

Summary counts of need also have the potential to
impact program planning and development
94
Concluding thoughts…

We need to strengthen our focus on prevention and
treatment of substance use by adolescents and young
adults

We need to target the latter phases of treatment to
impact the post-treatment recovery environment and/or
social risk groups that are the main predictors of long
term relapse

We need to move beyond focusing on acute episodes of
care to focus on continuing care and a recovery
management paradigm

We need both evidenced based practices, and practice
based evidence to improve outcomes
95
Sources and Related Work
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treatment careers. Journal of Substance Abuse Treatment, 28, S51-S62.
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NIDA Addiction Science and Clinical Practice, 4(1), 45-55
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checkups (RMC) for people with chronic substance use disorders. Evaluation and Program Planning,
26(3), 339-352.
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treatment: Preliminary Outcomes. Journal of Substance Abuse Treatment, 23(1), 21-32.
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Continuing Care on Continuing Care Linkage, Adherence, and Abstinence Following Residential
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construct validity of different starting and stopping rules for a Computerized Adaptive Test: The GAIN
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transitions from substance use to substance abuse treatment and from treatment to recovery. Poster
presented at the UCLA Center for Advancing Longitudinal Drug Abuse Research Annual Conference,
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98
Sources and Related Work
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of Problems on Drug Dependence (CPDD) Annual Meeting, San Juan, PR, June 16, 2008.
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99