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Addiction: What Every Judge Should Know Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation at “Addiction: What Every Judge Should.

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Presentation on theme: "Addiction: What Every Judge Should Know Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation at “Addiction: What Every Judge Should."— Presentation transcript:

1 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-DD- BX-0710 and using data from NIDA grants no. R01 DA15523, R37-DA11323 and CSAT contract no It is available electronically at The opinions are those of the authors do not reflect official positions of the government. Please address comments or questions to the author at or

2 2 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 Goals of this Presentation are to

3 3 Illustrate the Chronic Nature of Addiction and the Correlates of Recovery

4 4 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% Light Alcohol Use Only 47% No Alcohol or Drug Use 32% Source: 2002 NSDUH; Dennis & Scott 2007

5 5 Problems Vary by Age No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence NSDUH Age Groups Severity Category Adolescent Onset Remission Increasing rate of non- users Source: 2002 NSDUH; Dennis & Scott 2007

6 6 Higher Severity is Associated with Higher Annual Cost to Society Per Person $0 $231 $725 $406 $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence Median (50 th percentile) $948 $1,613 $1,078 $1,309 $1,528 $3,058 Mean (95% CI) This includes people who are in recovery, elderly, or do not use because of health problems Higher Costs Source: 2002 NSDUH; Dennis & Scott 2007

7 7 Brain Activity on PET Scan After Using Cocaine 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): Rapid rise in brain activity after taking cocaine Actually ends up lower than they started

8 8 Normal Cocaine Abuser (10 days) 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: , 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: , 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) Even after 100 days of abstinence activity is still low

9 9 Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine Serotonin Present in Cerebral Cortex Neurons Reduced in response to excessive use Still not back to normal after 7 years

10 10 Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.t pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front

11 11 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 (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 Overlap with Crime and Civil Issues

12 12 Substance Use Careers Last for Decades Cumulative Survival Years from first use to 1+ years abstinence Median of 27 years from first use to 1+ years abstinence Source: Dennis et al., 2005

13 13 Substance Use Careers are Longer the Younger the Age of First Use Cumulative Survival Years from first use to 1+ years abstinence under 15* * Age of 1 st Use Groups * p<.05 (different from 21+) Source: Dennis et al., 2005

14 14 Substance Use Careers are Shorter the Sooner People Get to Treatment Cumulative Survival * 10-19* Year to 1 st Tx Groups * p<.05 (different from 20+) Source: Dennis et al., 2005 Years from first use to 1+ years abstinence

15 15 Treatment Careers Last for Years Cumulative Survival Years from first Tx to 1+ years abstinence Median of 3 to 4 episodes of treatment over 9 years Source: Dennis et al., 2005

16 16 Lifetime Mental Health Diagnosis and Remission Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication 15% 13% 8% 25% 10% 8% 46% 31% 7% 20% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD Alcohol Drug Any Externalizing Conduct Oppositional Defiant Intermittent Explosive Attention Deficit Any Internalizing Anxiety : Mood : Posttraumatic Stress Lifetime Diagnosis 10% 15% 8%9% 4% 18% 12% 11% 3% 4% 7% Past Year Remission 66% 77% 83% 58% 89% 45% 50% 39% 56% 48% 40% Remission Rate (% Remission / % Dependent) SUD Remission Rates are BETTER than Most Major DSM Diagnoses

17 17 The Cyclical Course of Relapse, Incarceration, Treatment and Recovery (Adults) In the Community Using (53% stable) In Treatment (21% stable) In Recovery (58% stable) Incarcerated (37% stable) 6% 28% 13% 30% 8% 25% 31% 4% 44% 7% 29% 7% Treatment is the most likely path to recovery P not the same in both directions Over half change status annually Source: Scott, Dennis, & Foss (2005)

18 18 Source: Scott, Dennis, & Foss (2005) Predictors of Change Also Vary by Direction In the Community Using (53% stable) In Recovery (58% stable) 28% 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) 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)

19 19 Percent Sustaining Abstinence Through Year 8 by Duration of Abstinence at Year 7 36% 66% 86% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 to 12 months (n=157; OR=1.0) 1 to 3 years (n=138; OR=3.4) 3 to 5 years (n=59; OR=11.2) 5+ years (n=96; OR=11.2) Duration of Abstinence at Year 7 % Sustaining Abstinent through Year 8. It takes a year of abstinence before less than half relapse Even after 3 to 7 years of abstinence about 14% relapse Source: Dennis, Foss & Scott (2007) 1.22

20 20 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Using (N=661) 1 to 12 ms (N=232) 1 to 3 yrs (N=127) 3 to 5 yrs (N=65) 5 to 8 yrs (N=77) % Days of Psych Prob (of 30 days) % Above Poverty Line % Days Worked For Pay (of 22) % of Clean and Sober Friens % Days of Illegal Activity (of 30 days ) Other Aspects of Recovery by Duration of Abstinence of 8 Years 1-12 Months: Immediate increase in clean and sober friend 1-3 Years: Decrease in Illegal Activity; Increase in Psych Problems 3-5 Years: Improved Vocational and Financial Status 5-8 Years: Improved Psychological Status Source: Dennis, Foss & Scott (2007)

21 21 Death Rate by Years of Abstinence Source: Scott, Dennis, & Funk (2008) 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 It takes 4 or more years of abstinence for risk to get down to community levels 11.9% 7.1% 3.8%

22 22 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

23 23 Demonstrate the Feasibility of Managing Addiction Across Episodes of Treatment to Improve Long Term Outcomes

24 24 Lots of Geographic Variation in AOD Disorders Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

25 25 Cumulative Recovery Pattern at 30 months Source: Dennis et al, forthcoming 37% Sustained Problems 5% Sustained Recovery 19% Intermittent, currently in recovery 39% Intermittent, currently not in recovery The Majority of Adolescents Cycle in and out of Recovery

26 26 Recovery* by Level of Care * 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) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pre-IntakeMon 1-3Mon 4-6Mon 7-9Mon Percent in Past Month Recovery* Outpatient (+79%, -1%) Residential(+143%, +17%) Post Corr/Res (+220%, +18%) OP & Resid Similar CC better

27 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 Cost- Effectiveness 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

28 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 Assertive Continuing Care 2 (ACC-2) experiment with 342 adolescents discharged from residential substance abuse treatment and followed for 12 months in Assertive Outpatient Continuing Care Study (AOCCS) experiment with 320 adolescents admitted to outpatient substance abuse treatment and followed for 12 months in

29 29 Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17) Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Days after Residential (capped at 90) Percent of Clients Cont. Care Admis. Relapse

30 30 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)

31 31 Assertive Continuing Care (ACC) Hypotheses Assertive Continuin g Care General Continuin g Care Adherence Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA) Early Abstinence GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence Sustained Abstinence Early abstinence will be associated with higher rates of long term abstinence.

32 32 ACC Improved Adherence Source: Godley et al 2002, % 10% 20% 30% 40%50%60%70%80% WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/probation/school Follow up on referrals* ACC * p<.05 90% 100% Relapse prevention* Communication skills training* Problem solving component* Meet with parents 1-2x month* Weekly telephone contact* Referrals to other services* Discuss probation/school compliance* Adherence: Meets 7/12 criteria* UCC

33 33 GCCA Improved Early (0-3 mon.) Abstinence Source: Godley et al 2002, % 36% 38% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=2.16*)Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA 43% 55% High (7-12/12) GCCA * p<.05

34 34 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence Source: Godley et al 2002, % 22% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=11.16*)Alcohol (OR=5.47*) Marijuana (OR=11.15*) Early(0-3 mon.) Relapse 69% 59% 73% Early (0-3 mon.) Abstainer * p<.05

35 35 Relating Standards of Proof to Science Beyond a ReasonableDoubt Clear and ConvincingEvidence Preponderance of the Evidence ProbableCause ReasonableSuspicion Law Science 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, Multi- site, Independent, Replicated, Consistency) Pre-Post (multiple waves), Expert Consensus Correlation and Observational studies Case Studies, Focus Groups Pre-data Theories, Logic Models Anecdotes, Analogies STRONGER Source: Marlowe 2008 Weak Levels of Expert Testimony

36 36 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, Multi- site, Independent, Replicated, Consistency) Pre-Post (multiple waves), Expert Consensus Correlation and Observational studies Case Studies, Focus Groups Pre-data Theories, Logic Models Anecdotes, Analogies Relating Standards of Proof to Science Beyond a ReasonableDoubt Clear and ConvincingEvidence Preponderance of the Evidence ProbableCause ReasonableSuspicion Law Science STRONGER Adult Drug Treatment Courts 5 meta analyses of 76 studies found crime reduced 7-26% with $1.74 to $6.32 return on investment Family Drug Treatment Courts – one multisite quasi experiment with positive findings for parent and child DWI Treatment Courts – one quasi experiment and five observational studies with effect sizes of 0 to.45 and one quasi experiment (effect size=.29 to.57) Juvenile Drug Treatment Courts, Mental Health Treatment Courts – multiple small studies with mix of positive, null and negative findings

37 37 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.

38 38 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 Early Re-Intervention (ERI) Experiment 2 – 446 adults entering treatment followed for 5-years from Women Offenders – 450 women coming out of Cook County jail and followed for 3-years from Early Re-Intervention for Adolescents (ERI-A) – feasibility studies currently being conducted with over longitudinal data on over 4,000 adolescents

39 39 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

40 40 ERI-2 Time to Treatment Re-Entry 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% Days to Re-Admission (from 3 month interview) Percent Readmitted 1+ Times 55% ERI-2 RMC* (n=221) 37% ERI-2 OM (n=224) *Cohen's d=+0.41 Wilcoxon-Gehen Statistic (df=1) =16.56, p < = -384 days The size of the effect is growing every quarter Source: Scott & Dennis (in press) RMC increases the odds of transitioning from using to treatment within a quarter by 2.1

41 41 ERI-2: Impact on Outcomes at 45 Months 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Re-entered Treatment (d=0.22)* of 14 Subsequent Quarters in Need (d= 0.26) * of 1260 Days Abstinent (d= 0.26)*(d= -0.32)* Still in need of Tx at Mon 45 (d= -0.22) * Percentage OMRMC * p<.05 55% 41% 67% 50% 56% 38% Fewer Seq. Quarters in Need 74% More days of abstinent of 180 Days of Treatment 71% 61% RMC Increased Treatment Participation 47% Less likely to be in Need at 45m Source: Scott & Dennis (in press)

42 42 In the Community Using (75% stable) In Treatment (32% stable) In Recovery (58% stable) Incarcerated (56% stable) 4% 10% 23% 8% 13% 35% 7% 25% 6% 24% 3% ERI 2: Average Quarterly Transitions over 3 years 34% Changed Status in an Average Quarter Again the Probability of Entering Recovery is Higher from Treatment Source: Riley, Scott & Dennis, 2008

43 43 In the Community Using (75% stable) In Treatment (32% stable) 10% In Recovery (58% stable) 35% 25% Source: Riley, Scott & Dennis, 2008 ERI 2: Average Quarterly Transitions over 3 years 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) 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)

44 44 The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents In the Community Using (75% stable) In Treatment (48% stable) In Recovery (62% stable) Incarcerated (46% stable) 5%5% 12% 7%7% 20% 24% 10% 26% 7 % 19% 7%7% 27% 3%3% Source: Dennis et al CSAT AT data set Avg of 39% change status each quarter P not the same in both directions Treatment is the most likely path to recovery More likely than adults to stay 90 days in treatment (OR=1.7) More likely than adults to be diverted to treatment (OR=4.0)

45 45 In the Community Using (75% stable) 12% 27% 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) * 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. In Recovery (62% stable) 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) The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents

46 46 In the Community Using (75% stable) In Treatment (48 v 35% stable) 7%7% 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) The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents Source: Dennis et al CSAT AT data set

47 47 In the Community Using (75% stable) In Treatment (48 v 35% stable) In Recovery (62% stable) 26% 19% 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) * 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. Source: Dennis et al CSAT AT data set

48 48 In the Community Using (75% stable) In Recovery (62% stable) The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents * 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 20% 10% Incarcerated (46% stable) Probability of Going to Using vs. Early “Recovery” (+ good) + Recovery Environment (r)* (3.33) Source: Dennis et al CSAT AT data set

49 49 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

50 50 Identify the Common Gaps in the Existing Treatment System and What it Means to Move it Toward Evidenced Based Practice

51 51 Substance Use Disorder & Treatment Participation Rates by Age Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH to to Drug Disorder Alcohol Disorder Any Disorder Drug Treatment Alcohol Treatment Any Treatment Less than 1 in 17 adolescents, 1 in 22 young adults, and 1 in 12 adults

52 52 The Majority Stay in Tx Less than 90 days 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): Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) , Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from OutpatientIntensive Outpatient Short Term Residential Long Term Residential Level of Care Median Length of Stay in Days Half are gone within 8 weeks, less than 25% stay the 90 days recommended by NIDA researchers

53 53 Less Than Half Are Positively Discharged 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): Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) , Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% OutpatientIntensive Outpatient Short Term Residential Long Term Residential Level of Care Discharge Status Other Terminated Dropped out Completed Transferred Less than 10% are transferred

54 54 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

55 55 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

56 56 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

57 57 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

58 58 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

59 59 Components of Comprehensive Drug Addiction Treatment Recommended by NIDA

60 60 Two Key Resources Available from NIDA ( )

61 61 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

62 62 Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis Source: Adapted from Lipsey, 1997, 2005 Average Practice The more features, the lower the recidivism

63 63 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 Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004 NOTE: There is generally little or no differences in mean effect size between these brand names

64 64 Impact of Simple On-site Urine Protocol with Feedback On False Negative Urines Source: Scott & Dennis (in press) On-site Urine Feedback Protocol associated with Lower False Negatives (19 v 3%)

65 65 Implementation is Essential ( Reduction in Recidivism from.50 Control Group Rate) The effect of a well implemented weak program is as big as a strong program implemented poorly 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

66 66 Range of Effect Sizes (d) of MET/CBT for Change in Days of Abstinence by Site Experiment Sites (f=0.39) (median within site d=0.29) 36 Replication Sites (f=0.21) (median within site d=0.49) Cohen’s d Source: Dennis, Ives, & Muck, 2008 Replication Sites Averaged Better than Experiment 75% above median of Experiment 6 programs completely above Experiment

67 67 Number of Problems by Level of Care (Triage) * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824) Clients entering Short Term Residential (usually dual diagnosis) have 5.5 times higher odds of having 5+ major problems*

68 68 No. of Problems* by Severity of Victimization Severity of Victimization * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Source: Dennis et al 2009; CSAT 2007 Adolescent Treatment Outcome Data Set (n=12,824) Those with high lifetime levels of victimization have 13 times higher odds of having 5+ major problems*

69 69 Victimization and Level of Care Interact to Predict Outcomes Source: Funk, et al., Intake6 MonthsIntake6 Months Marijuana Use (Days of 90) OP -HighOP - Low/ModResid-HighResid - Low/Mod. CHS Outpatient CHS Residential Traumatized groups have higher severity High trauma group does not respond to CHS OP Both groups respond to residential treatment

70 70 Crime/Violence and Substance Problems Interact to Predict Any Recidivism Low Mod. High Low Mod. High 0% 20% 40% 60% 80% 100% Source: CYT & ATM Data 12 month recidivism Crime/ Violence predicted recidivism Substance Problem Severity predicted recidivism Knowing both was the best predictor Substance Problem Scale Crime and Violence Scale

71 71 Crime/Violence and Substance Problems Interact Differently to Predict Recidivism to Violent Crime Low Mod. High Low Mod. High Source: CYT & ATM Data 12 month recidivism To violent crime or arrest Substance Problem Scale Crime and Violence Scale 0% 20% 40% 60% 80% 100% Crime/ Violence predicted violent recidivism (Intake) Substance Problem Severity did not predict violent recidivism Knowing both was the best predictor

72 72 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 Problems With the Treatment System

73 73 Demonstrate the Usefulness of Practice Based Evidence to Inform Clinical Decision Making About Placement and Treatment Planning

74 74 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.

75 75 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

76 76 CSAT Adolescent Treatment GAIN Data from 203 level of care x site combinations Outpatient General Group Home Short-Term Residential Outpatient Continuing Care Intensive Outpatient Long-term Residential Moderate-Term Residential Early Intervention Other Corrections Levels of Care Source: Dennis, Funk & Hanes-Stevens, 2008

77 77 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

78 78 Ratings of Problem Severity (x-axis) by Treatment Utilization (y-axis) by Population Size (circle size) 12% 20% 14% 8% 14% 12% Average Current Problem Severity Average Current Treatment Utilization. A Low-Low B Low- Mod C Mod-Mod D Hi-Low E Hi- Mod F. Hi- Hi (CC) G. Hi-Mod (Env Sx/ PH Tx) 9% H. Hi-Hi (Intx Sx; PH/MH Tx) 12%

79 79 While over 50% go to outpatient in 7 of 8 clusters, there are a range of placements in each cluster

80 80 Variance Explained in NOMS Outcomes \1 Past month \2 Past 90 days *All statistically Significant 26% 24% 11% 25% 15% 33% 26% 18% 14% 8% 24% 0%5%10%15%20%25%30%35% No AOD Use No AOD related Problem No Health Problems No Mental Health Problems No Illegal Activity No JJ System Involve. Living in Community No Family Prob. Vocationally Engaged Social Support Count of above Percent of Variance Explained

81 81 Predicted Count of Positive Outcomes by Level of Care: Cluster A Low - Low (n=1,025) Person “A” does better in Outpatient Person “B” does better in Higher Levels of Care

82 82 Best Level of Care*: Cluster A Low - Low (n=1,025)

83 83 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

84 84 Best Level of Care*: Cluster C Mod-Mod (n=1209)

85 85 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

86 86 Best Level of Care*: Cluster F Hi-Hi (CC) (n=968)

87 87 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

88 88 Best Level of Care*: Cluster G Hi-Mod (Env/PH) (n=749)

89 89 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

90 90 Summary of Best Level Of Care Based on Cluster and Expected Outcome 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Higher than OP 0.4% Residential 14.1%7.6%38.3%88.3%94.1%17.2%8.6% IOP/OPCC 27.9%0.0% OPCC 0.4%30.2%1.1%78.2%81.5% IOP 10.5%23.6%0.0%4.6%9.9% OP 99.6%75.1%38.6%33.8%10.6%5.9%0.0% 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) Cluster G Hi-Mod (Env/PH) Cluster H Hi-Hi (Intx/PH/MH Cluster F Hi-Hi (CC) (n=968) * * * * **

91 91 Change in Days Abstinent (while in community) by Level of Care and Gender Source: CSAT 2007 AT Outcome Data Set (n=11,013)

92 92 MALES: Change in Days Abstinent in Community by type of Outpatient Approach Source: CSAT 2007 AT Outcome Data Set (n=11,013) IntakeLast Follow-up Days of abstinence in Community MST (d=0.87) (n=25) Other Mot. Interv (d=0.79) (n=130) ACRA/ACC (d=0.53) (n=460) Total (d=0.33) (n=6272) CHS OP (d=0.15) (n=281) MDFT (d=0.07) (n=99) METCBT7 (d=-0.03) (n=93) FSN (d=0.48) (n=337) Other (d=0.43) (n=482) EMPACT (d=0.4) (n=102) METCBT5 (d=0.33) (n=3368) Other CBT (d=0.32) (n=150) Seven Challenges (d=0.27) (n=93) METCBT12 (d=0.2) (n=506) EPOCH (d=0.18) (n=146)

93 93 FEMALES: Change in Days Abstinent in Community by type of Outpatient Approach Source: CSAT 2007 AT Outcome Data Set (n=11,013) IntakeLast Follow-up Days of abstinence in Community Total (d=0.42) (n=2339) EMPACT (d=0.62) (n=31) Other (d=0.52) (n=120) CHS OP (d=0.48) (n=97) METCBT12 (d=0.48) (n=174) Seven Challenges (d=0.44) (n=51) FSN (d=0.41) (n=96) Other CBT (d=0.41) (n=35) METCBT5 (d=0.4) (n=1491) METCBT7 (d=0.38) (n=40) MDFT (d=0.36) (n=28) ACRA/ACC (d=0.35) (n=86) EPOCH (d=0.02) (n=29) Other Mot. Interv (d=0.87) (n=50) MST (d=0.86) (n=11)

94 94 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

95 95 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

96 96 Sources and Related Work 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. Dennis, M.L., Coleman, V., Scott, C.K & Funk, R (forthcoming). The Prevalence of Remission from Major Mental Health Disorder in the US: Findings from the National Co morbidity Study Replication. Dennis, M.L., Foss, M.A., & Scott, C.K (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), Dennis, M.L., Funk, R.R. & Hanes-Stevens, L. (2008). Moving the field from ‘no wrong door’ to the ‘best door’: An actuarial estimate of expected outcomes by level of care among adolescents presenting for substance abuse treatment. Joint Meeting on Adolescent Treatment Effectiveness, March 25-27, 2008, Washington, DC. 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. and Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment,27, Dennis, M.L., Ives, M., White, M., & Muck, R. (2008). The Strengthening Communities for Youth (SCY) initiative: A cluster analysis of the services received, their correlates and how they are associated with outcomes. Journal of Psychoactive Drugs, 40(1), Dennis, M. L., Scott, C. K. (2007). Managing Addiction as a Chronic Condition. Addiction Science & Clinical Practice, 4(1), Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment careers. Journal of Substance Abuse Treatment, 28, S51-S62. Dennis, M. L., & Scott, C. K. (2007). Managing substance use disorders (SUD) as a chronic condition. NIDA Addiction Science and Clinical Practice, 4(1), Dennis, M. L., Scott, C. K., & Funk, R. (2003). An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. Evaluation and Program Planning, 26(3), Dennis, M.L., White, M., Ives, M.I (2009). Individual characteristics and needs associated with substance misuse of adolescents and young adults in addiction treatment. In Carl Leukefeld, Tom Gullotta and Michele Staton Tindall (Ed.), Handbook on Adolescent Substance Abuse Prevention and Treatment: Evidence-Based Practice. New London, CT: Child and Family Agency Press.

97 97 Sources and Related Work Epstein, J. F. (2002). Substance dependence, abuse and treatment: Findings from the 2000 National Household Survey on Drug Abuse (NHSDA Series A-16, DHHS Publication No. SMA ). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Retrieved from 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): Funk, R. R., McDermeit (Ives), 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, 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(2 suppl), Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. L. (2002). A randomized field trial of an assertive aftercare protocol for adolescents following discharge from residential substance abuse treatment: Preliminary Outcomes. Journal of Substance Abuse Treatment, 23(1), Godley, M.D., Godley, S.H., Dennis, M.L., Funk, R.R., & Passetti, L.L. (2007). The Effect of Assertive Continuing Care on Continuing Care Linkage, Adherence, and Abstinence Following Residential Treatment for Adolescents. Addiction, 102(1), 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, 19(1), Lipsey, M. W. (1997). What can you build with thousands of bricks? Musings on the cumulation of knowledge in program evaluation. New Directions for Evaluation, 76, Lipsey, M. W. (2005). What works with juvenile offenders: Translating research into practice. Paper presented at the Adolescent Treatment Issues Conference, Tampa. Lipsey, M. W., Chapman, G. L., & Landenberger, N. A. (2001). Cognitive-behavioral programs for offenders. The Annals of the American Academy of Political and Social Science, 578, Marlowe, D. (2008). Recent studies of drug courts and DWI courts: Crime reduction and cost savings. National Institute on Drug Abuse (2000). Principles of Drug Addiction Treatment: A Research-Based Guide. Rockville, MD: Author. NIH Publication No On line at

98 98 Sources and Related Work National Institute on Drug Abuse (2006). Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide. Rockville, MD: Author. NIH Publication No On line at Office Applied Studies (2002). Analysis of the 2002 National Survey on Drug Use and Health (NSDUH) on line at Office Applied Studies (2002). Analysis of the 2002 Treatment Episode Data Set (TEDS) on line data at ) Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) , Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from rptd.pdf. rptd.pdf Office of Applied Studies (2006). Results from the 2005 National Survey on Drug Use and Health: National Findings Rockville, MD: Substance Abuse and Mental Health Services Administration. Riley, B. B., Conrad, K. J., Bezruczko, N., & Dennis, M. (2007). Relative precision, efficiency and construct validity of different starting and stopping rules for a Computerized Adaptive Test: The GAIN Substance Problem Scale. Journal of Applied Measurement, 8(1), Riley, B.B.,, Scott, C.K, & Dennis, M.L. (2008). The effect of recovery management checkups on 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, August 13-15, 2008, Los Angless, CA. Rush, B., Dennis, M.L., Scott, C.K, Castel, S., & Funk, R.R. (2008). The Interaction of Co-Occurring Mental Disorders and Recovery Management Checkusp on Treatment Participation and Recovery. Scott, C. K., & Dennis, M. L. (in press). Results from Two Randomized Clinical Trials evaluating the impact of Quarterly Recovery Management Checkups with Adult Chronic Substance Users. Addiction. Scott, C. K., Dennis, M. L., & Foss, M. A. (2005). Utilizing recovery management checkups to shorten the cycle of relapse, treatment re-entry, and recovery. Drug and Alcohol Dependence, 78,

99 99 Sources and Related Work Scott, C. K., Dennis, M. L., & Funk, R.R. (2008). Predicting the relative risk of death over 9 years based on treatment completion and duration of abstinence. Poster 119 at the College of Problems on Drug Dependence (CPDD) Annual Meeting, San Juan, PR, June 16, Available at Scott, C. K., Foss, M. A., & Dennis, M. L. (2005). Pathways in the relapse, treatment, and recovery cycle over three years. Journal of Substance Abuse Treatment, 28, S61-S70. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11: , 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: , Waldron, H., Turner, C. (in press). Psychosocial Treatments for Adolescent Substance Abuse: A Review and Meta-Analyses. Journal of Clinical Child & Adolescent Psychology


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