1. Chestnut Health Systems, Normal, IL
Dennis
4/12/2017
When the Rite of Passage Goes Wrong: What Parents Should Know Abuse Adolescent Drug and Alcohol Use
Michael Dennis, Ph.D.
Chestnut Health Systems,
Normal, IL
Presentation on October 29, 2008 at a pre-conference session sponsored by the Council on Chemical Abuse in cooperation with Alvernia College and the Caron Treatment Centers in Reading, PA.. This presentation reports on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contracts and , as well as several individual CSAT, NIAAA, NIDA and private foundation grants. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at or by contacting Joan Unsicker at 448 Wylie Drive, Normal, IL 61761, phone: (309) , Fax: (309) ,
Chestnut Health Systems

2. Goals of this Presentation are to
Dennis
4/12/2017
Goals of this Presentation are to
Examine the prevalence, course, and consequences of adolescent substance use, co-occurring disorders and the unmet need for treatment overall
Summarize major trends in the adolescent treatment system and Pennsylvania
Highlight what it takes to move the field towards evidenced-based practice related to assessment, treatment, program evaluation and planning
Present the findings from several recent treatment studies on substance abuse treatment research, trauma and violence/crime
Chestnut Health Systems

3. Dennis
4/12/2017
Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246)
Dependence 5%
Abuse 4%
No Alcohol or
Regular AOD
Drug Use
32%
Use 8%
Any Infrequent
Drug Use 4%
This figure shows the prevalence of substance use and disorders among the U.S. household population in 2002.
5% meet criteria for dependence in the past year
4% meet criteria for abuse in the past year
8% were regularly using drugs monthly or more often
or alcohol to the point of intoxication weekly or more often
4% had used drugs less than monthly
47% reported using alcohol at a lower frequency or not to intoxication
32% reported no alcohol or drug use in the past year.
Thus those with abuse and dependence are only a subset of people currently using alcohol or other drugs.
Light Alcohol
Use Only 47%
Source: 2002 NSDUH
Chestnut Health Systems

4. Problems Vary by Age Increasing rate of non-users Adolescent Onset
Dennis
4/12/2017
Problems Vary by Age
NSDUH Age Groups
Increasing rate of non-users
100
Severity Category 90
Adolescent Onset
Remission
No Alcohol or Drug Use 80 70
Light Alcohol Use Only 60
Any Infrequent Drug Use 50 40
Regular AOD Use 30
This figure shows how the prevalence of these past year severity categories vary by age.
1- Substance use disorders typically on set during adolescents and young adult hood. In fact, 90% of all adults with dependence started using under the age of 18, half under the age of 15.
2- After several decades, the rates of abuse and dependence do decrease as people go into remission, incarceration or die. Epidemiological studies of people with lifetime substance dependence suggest that 58% eventually enter sustained recovery (i.e., no symptoms for the past year) -- a rate that is considerably better than the 39% average rate of recovery across psychiatric disorders (Kessler, 1994; see also Dawson, 1996; Robins & Regier, 1991).
3 – Notice how the rates of no use go up with age.
Thus substance use disorders on set early and last for many years, but do get better over time.
Abuse 20 10
Dependence
65+
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Source: 2002 NSDUH and Dennis et al forthcoming
Chestnut Health Systems

5. Crime & Violence by Substance Severity
Age 12-17
Source: NSDUH 2006

6. Family, Vocational & MH by Substance Severity
Age 12-17
Source: NSDUH 2006

7. Brain Activity on PET Scan
Dennis
4/12/2017
Brain Activity on PET Scan
After Using Cocaine
Rapid rise in brain activity after taking cocaine
Slide 7: This is literally the brain on drugs
When someone gets “high” on cocaine, where does the cocaine go in the brain? With the help of a radioactive tracer, this PET scan shows us a person’s brain on cocaine and the area of the brain, highlighted in yellow, where cocaine is “binding” or attaching itself. This PET scan shows us minute by minute, in a time-lapsed sequence, just how quickly cocaine begins affecting a particular area of the brain.
We start in the upper left hand corner. You can see that 1 minute after cocaine is administered to this subject nothing much happens. All areas of the brain are functioning normally. But after 3 to 4 minutes [the next scan to the right], we see some areas starting to turn yellow. These areas are part of a brain structure called the striatum [stry-a-tum] that is the main target in the brain bound and activated by cocaine.
At the 5- to 8-minute interval, we see that cocaine is affecting a large area of the brain. After that, the drug’s effects begin to wear off. At the 9- to 10-minute point, the high feeling is almost gone. Unless the abuser takes more cocaine, the experience is over in about 20 to 30 minutes.
Scientists are doing research to find out if the striatum produces the “high” feeling and controls our feelings of pleasure and motivation. One of the reasons scientists are curious about specific areas of the brain affected by drugs, such as cocaine, is to develop treatments for people who become addicted to these drugs. Scientists hope to find the most effective way to change an addicted brain back to normal functioning.
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):
Chestnut Health Systems

8. Brain Activity on PET Scan
Dennis
4/12/2017
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)
Slide 8: Long-term effects of drug abuse
The images in these PET scans, which depict brain glucose utilization (a marker of brain activity), show that once the brain becomes addicted to a drug like cocaine, it is affected for a long, long time. In other words, once addicted, the brain is literally changed. Let’s see how.
In this slide, increasing amounts of brain function are measured by yellow or red. The top row shows a normal functioning brain without drugs. You can see a lot of brain activity. In other words, there is a lot of yellow and red color.
The middle row shows a cocaine addict’s brain after 10 days without any cocaine use at all. What is happening here? [Pause for response.] Less yellow and red means less normal activity occurring in the brain—even after the cocaine abuser has abstained from the drug for 10 days.
The third row shows the same addict’s brain after 100 days without any cocaine. We can see a little more yellow and red, so there is some improvement— more brain activity—at this point. But the addict’s brain is still not back to a normal level of functioning. . . more than 3 months later. Scientists are concerned that there may be areas in the brain that never fully recover from drug abuse and addiction.
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: , 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: , 1993.
Chestnut Health Systems

9. Slide 1: Introduction: long-term effects of ecstasy
Dennis
4/12/2017
Slide 1: Introduction: long-term effects of ecstasy
An effective way of starting a presentation is to present something interesting or provocative. This first slide shows sections taken from the neocortex of monkeys that were given ecstasy twice a day for 4 days (control monkeys were given saline). The section on the left, taken from the brain of a control monkey, shows the presence of a lot of serotonin. The middle section shows a section from a monkey two weeks after receiving ecstasy. Point out that most of the serotonin is gone. The section on the right shows a section from a monkey 7 years after receiving ecstasy. Point out that although there has been some recovery of serotonin, the brain still has not returned to normal. Indicate that you will discuss this in your talk in more detail. Introduce the purpose of your presentation. Indicate that you will explain how ecstasy interacts with specific targets in the brain and what can happen after repeated or long-term use. Tell the students that you will review how neurons communicate with each other and how ecstasy alters this communication, resulting in changes in mood, behavior, and memory.
Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine
Chestnut Health Systems

10. Adolescent Brain Development Occurs from the Inside to Out and
Dennis
4/12/2017
Slide 4: The brain is your body’s “Command Central”
Your brain controls more than the way you think. The brain controls our physical sensations and body movements. How we understand what we see, hear, smell, taste, and touch. Our sense of balance and coordination. Memory. Feelings of pleasure and reward. The ability to make judgments. When we catch a football, dance, jog, speak, sing, laugh, whistle, smile, cry—that’s our brain receiving, processing, and sending out messages to different parts of our body.
When we feel good for whatever reason—laughing with a friend or seeing a good movie or eating our favorite ice cream—the brain’s reward system is activated. As we said before, the reward system is the part of the brain that makes you feel good. The reward system is a collection of neurons that release dopamine, a neurotransmitter. When dopamine is released by these neurons, a person feels pleasure.
Scientists have linked dopamine to most drugs of abuse—cocaine, marijuana, heroin, alcohol, and nicotine. These drugs all activate the reward system and cause neurons to release large damaging amounts of dopamine. Over time, drugs change this part of the brain. As a result, things that used to make you feel good—like eating ice cream, skateboarding, or getting a hug—no longer feel as good.
Slide 3: Brain regions and neuronal pathways
Certain parts of the brain govern specific functions. Point to areas such as the sensory (blue), motor (orange) and visual cortex (yellow) to highlight their specific functions. Point to the cerebellum (pink) for coordination and to the hippocampus (green) for memory. Indicate that nerve cells or neurons connect one area to another via pathways to send and integrate information. The distances that neurons extend can be short or long. For example, point to the reward pathway (deep orange). Explain that this pathway is activated when a person receives positive reinforcement for certain behaviors ("reward"). Indicate that you will explain how this happens when a person takes an addictive drug. As another example, point to the thalamus (magenta). This structure receives information about pain coming from the body (magenta line within the spinal cord), and passes the information up to the cortex. Tell the audience that you can look at this in more detail.
pain
Adolescent Brain Development Occurs from the Inside to Out and
from Back to Front
Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.
Chestnut Health Systems

11. Median of 27 years from first use to 1+ years abstinence
Dennis
4/12/2017
Substance Use Careers Last for Decades
1.0
Median of 27 years from first use to 1+ years abstinence .9
Cumulative Survival .8 .7
Years from first use to 1+ years abstinence .6 .5 .4 .3
Explain survival analysis -- why you do it…and how
Time frames related to age of use, treatment, and death were measured across all sources and waves of information (taking the earliest first use, treatment episode, and 12 month period of abstinence or death).
Age at last use was defined as the age when a person first completed a period of 12 month abstinence
Censoring 35 or 2.6% of the people who died in 3 years
Durations were estimated with Cox Proportional Hazards Regression
censoring people who were in treatment or still using,
censoring years past which we had less than 100 people to make the estimate, and
creating a 30 year window of observation on the trajectory of substance use disorders starting at the time of first use .2 .1
0.0 5 10 15 20 25 30
Source: Dennis et al., 2005
Chestnut Health Systems

12. Substance Use Careers are Longer the Younger the Age of First Use
Dennis
Substance Use Careers are
Longer the Younger the Age of First Use
4/12/2017
1.0
Age of 1st Use
Groups .9
Cumulative Survival .8 .7
Years from first use to 1+ years abstinence .6 .5
under 15* .4
15-20* .3 .2
21+ .1
0.0
* p<.05 (different from 21+) 5 10 15 20 25 30
Source: Dennis et al., 2005
Chestnut Health Systems

13. Substance Use Careers are Shorter the Sooner People Get to Treatment
Dennis
Substance Use Careers are
Shorter the Sooner People Get to Treatment
4/12/2017
1.0
Year to 1st Tx
Groups .9
Cumulative Survival .8 .7
Years from first use to 1+ years abstinence
20+ .6 .5 .4 .3 .2
10-19* .1
0.0
0-9* 5 10 15 20 25 30
* p<.05 (different from 20+)
Source: Dennis et al., 2005
Chestnut Health Systems

14. Median of 3 to 4 episodes of treatment over 9 years
Dennis
4/12/2017
Treatment Careers Last for Years
1.0 .9
Cumulative Survival .8
Median of 3 to 4 episodes of treatment over 9 years .7
Years from first Tx to 1+ years abstinence .6 .5 .4 .3
Figure shows the time from 1st treatment to 1+ years of abstinence or death, the median was 8 years with wide inter-quartile range (3 to 20 years). .2 .1
0.0 5 10 15 20 25
Source: Dennis et al., 2005
Chestnut Health Systems

15. Dennis
4/12/2017
Key Implications
Adolescence is the peak period of risk for and actual on-set of substance use disorders
Adolescent substance use can have short and long terms costs to society
There are real and often lasting consequence of adolescent substance use on brain functioning and brain development
Earlier Intervention during adolescence and young adult hood can reduce the duration of addiction careers
Chestnut Health Systems

16. Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S.
Dennis
Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S.
4/12/2017
15% drop off from 160,750 in to 136,660 in 2006
69% increase from
95,017 in 1992
to 160,750 in 2002
Source: Office of Applied Studies Treatment Episode Data Set (TEDS)
Chestnut Health Systems

17. Median Length of Stay is only 50 days
Total
50 days
(61,153 discharges)
LTR
Less than 25% stay the 90 days or longer time recommended by NIDA Researchers
49 days
(5,476 discharges)
STR
21 days
(5,152 discharges)
Level of Care
Detox
3 days
(3,185 discharges)
IOP
46 days
(10,292 discharges)
Outpatient
59 days
(37,048 discharges) 30 60 90
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 .

18. 53% Have Unfavorable Discharges
Despite being widely recommended, only 10% step down after intensive treatment
53% Have Unfavorable Discharges
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 .

19. Past Year Alcohol or Drug Abuse or Dependence
Dennis
Past Year Alcohol or Drug Abuse or Dependence
4/12/2017
8.8% PA vs.
8.9% National
Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH
Chestnut Health Systems

20. Adolescent SUD & Treatment
Dennis
Adolescent SUD & Treatment
4/12/2017
Still less than 1 in 15 get treatment
Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH
Chestnut Health Systems

21. 22% decrease in the past decade
Change in PA Public Treatment Admissions: Level of Care from 1992 to 2006
Dramatic Growth in
22% decrease in the past decade
Decreased use of Detox
Source: OAS, 2006 – TEDS Data

22. Change in PA Public Treatment Admissions: Referral Source from 1995 to 2006
Close link to Juv. Just.
Source: OAS, 2006 – TEDS Data

23. Change in PA Public Treatment Admissions: Referral Source from 1995 to 2006
Marijuana and Alcohol are the most common problems
6,000
Marijuana
(149%)
Alcohol
(14%)
5,000
Cocaine
(89%)
4,000
Hallucinogens
(-76%)
3,000
Opioids
(1429%)
Opioid and Psychotropics are less common but growing fast
Other Stimulants
(-24%)
2,000
Psychotropics
(329%)
1,000
Methamphetamine
(173%) -
Other
(79%)
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Source: OAS, 2006 – TEDS Data

24. Summary of Problems in the Treatment System
Dennis
4/12/2017
Summary of Problems in the Treatment System
The public systems is changing size, referral source, and focus
Less than 50% stay 50 days (~7 weeks)
Less the 25% stay the 3 months recommended by NIDA researchers
Less than half have positive discharges
After intensive treatment, less than 10% step down to outpatient care
Major problems are not reliably assessed (if at all)
Difficult to link assessment data to placement or treatment planning decisions
Chestnut Health Systems

25. Dennis
4/12/2017
So what does it mean to move the field towards Evidence Based Practice (EBP)?
Introducing explicit intervention protocols that are
Targeted at specific problems/subgroups and outcomes
Having explicit quality assurance procedures to cause adherence at the individual level and implementation at the program level
Having the ability to evaluate performance and outcomes
For the same program over time,
Relative to other interventions
Introducing reliable and valid assessment that can be used
At the individual level to immediately guide clinical judgments about diagnosis/severity, placement, treatment planning, and the response to treatment
At the program level to drive program evaluation, needs assessment, performance monitoring and long term program planning
Chestnut Health Systems

26. Major Predictors of Bigger Effects
Chose a strong intervention protocol based on prior evidence
Used quality assurance to ensure protocol adherence and project implementation
Used proactive case supervision of individual
Used triage to focus on the highest severity subgroup

27. Impact of the numbers of Favorable features on Recidivism (509 JJ studies)
Average Practice
Source: Adapted from Lipsey, 1997, 2005

28. Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing 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

29. Need for Short Protocols Targeted at Specific Issues:
Detoxification services and medication, particularly related to opioid and methamphetamine use
Tobacco cessation
Adolescent psychiatric services related to depression, anxiety, ADHD, and conduct disorder
Trauma, suicide ideation, & parasuicidal behavior
Need for child maltreatment interventions (not just reporting protocols)
HIV Intervention to reduce high risk pattern of sexual behavior
Anger Management
Problems with family, school, work, and probation
Recovery coaches, recovery schools, recovery housing and other adolescent oriented self help groups / services

30. Recovery* by Level of Care
Dennis
4/12/2017
Recovery* by Level of Care
100%
Outpatient (+79%, -1%)
90%
Residential(+143%, +17%)
80%
Post Corr/Res (+220%, +18%)
70%
CC better
60%
Percent in Past Month Recovery*
50%
40%
OP & Resid Similar
30%
20%
If we define recovery more as no past month use, abuse or dependence symptoms while living in the community (vs. a controlled environment like residential treatment or incarceration), about a third of the adolescents get better after treatment and the effects are largely sustained at the group level.
However each month some relapse and some go into early remission. The best results come from further continuing care – where half to two thirds are in recovery. Hence the increasing focus of CSAT’s Adolescent Treatment program on continuing care.
10% 0%
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)
Chestnut Health Systems

31. Need for Tracks, Phases and Continuing Care
Almost a third of the adolescents are “returning” to treatment, 23% for the second or more time
We need to understand what did and did not work the last time and have alternative approaches
We need tracks or phases that recognize that they may need something different or be frustrated by repeating the same material again and again
We need to have better step down and continuing care protocols

32. The best is to have a strong program implemented well
Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)
The best is to have a strong program implemented well
The effect of a well implemented weak program is as big as a strong program implemented poorly
Thus one should optimally pick the strongest intervention that one can implement well
Source: Adapted from Lipsey, 1997, 2005

33. On-site proactive urine testing can be used to reduce false negatives by more than half
Reduction in false negative reports at no additional cost
Effects grow when protocol is repeated

34. Implications of Implementation Science
Can identify complex and simple protocols that improve outcomes
Interventions have to be reliably delivered in order to achieve reliable outcomes
Simple targeted protocols can make a big difference
Need for reliable assessment of need, implementation, and outcomes

35. GAIN Clinical Collaborators Adolescent and Adult Treatment Program
Dennis
4/12/2017
GAIN Clinical Collaborators
Adolescent and Adult Treatment Program
New Hampshire
Washington
Vermont
Montana
North
Maine
Dakota
Oregon
Minnesota
Massachusetts
South
Idaho
Wisconsin
Dakota
New York
Wyoming
Michigan
Rhode Island
Iowa
Pennsylvania
Nebraska
Connecticut
Nevada
Ohio
Illinois
Indiana
New Jersey
Utah
California
Colorado
W. Virginia
Delaware
Kansas
Missouri
Virginia
Kentucky
Maryland
North Carolina
Oklahoma
Tennessee
District Of Columbia
Arizona
New Mexico
Arkansas
South Carolina
Mississippi
Georgia
Number of GAIN Sites
Alabama
This slide shows the geographic diversity of this collaboration, which includes 45 of 50 states, DC and 3 Canadian provinces.
Highlighted with starts are locations where one or more state or county systems have or are negotiating to go system wide with these tools.
1 to 10
Texas
Louisiana
11 to 25
Alaska
26 to 130
Florida
GAIN State System
GAIN-SS State or
Hawaii
County System
Virgin Islands
Puerto Rico
10/07
Chestnut Health Systems

36. Dennis
4/12/2017
CSAT GAIN Data (n=15,254)
CSAT data dominated by Male, Caucasians, age 15 to 17
CSAT data dominated by Outpatient
CSAT residential more likely to be over 30 days
*Any Hispanic ethnicity separate from race group.
Sources: CSAT AT 2007 dataset subset to adolescent studies (includes 2% 18 or older).
Chestnut Health Systems

37. Substance Use Problems
Dennis
4/12/2017
Substance Use Problems
While all have lifetime diagnoses, most of the adolescents are presenting meeting criteria for their diagnoses in the past 12 months - about half for dependence. Some withdrawal symptoms are common, but the more severe withdrawal typical of alcohol or opioid users is more limited. While virtually all of the adolescents can identify reasons to quit and over a third have already been in treatment – only 30% acknowledge that they have an AOD problem and less than 1 in 4 think they need treatment. This illustrates the importance of motivational interviewing and other techniques to engage and retain them in treatment.
Source: CSAT 2007 AT Outcome Data Set (n=12,601)
Chestnut Health Systems

38. Past 90 day HIV Risk Behaviors
Dennis
4/12/2017
Past 90 day HIV Risk Behaviors
They are very likely to be sexually active and exhibit multiple risk behaviors, including being victimized – which WHO says is actually the leading risk factor for HIV among women. While need use is relatively rare, it is of course a key risk factor for those engaging in it.
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Chestnut Health Systems

39. Co-Occurring Psychiatric Problems
Dennis
4/12/2017
Co-Occurring Psychiatric Problems
Co-occurring psychiatric problems are the norm among adolescents presenting for substance abuse treatment. The most common are externalizing conditions like conduct disorder and ADHD. There are also significant rates of depression, trauma and anxiety disorders. The lower half of this panel shows that a wide range of other key psychiatric issues are also present including any victimization, high severity victimization (i.e., that occurred multiple times, multiple people, someone they trusted, involved sexual penetration or near death, that people did not believe when they sought help), running away, homicidal or suicidal thoughts, and self multilation.
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Chestnut Health Systems

40. Past Year Violence & Crime
Dennis
4/12/2017
Past Year Violence & Crime
This figure shows that their legal problems go far beyond simple use or possession. In fact most self report being committing acts of physical violence towards others and a wide range of illegal activities. Most are also already involved in the juvenile justice system.
*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Chestnut Health Systems

41. Multiple Problems* are the Norm
Dennis
4/12/2017
Multiple Problems* are the Norm
Few present with just one problem (the focus of traditional research)
Most acknowledge 1+ problems
In fact, 45%present acknowledging 5+ major problems
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Chestnut Health Systems

42. Number of Problems by Level of Care
Dennis
4/12/2017
Number of Problems by Level of Care
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
Chestnut Health Systems

43. No. of Problems* by Severity of Victimization
Dennis
4/12/2017
No. of Problems* by Severity of Victimization
Those with high lifetime levels of victimization have 117 times higher odds of having 5+ major problems*
Severity of Victimization
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Chestnut Health Systems

44. The Cyclical Course of Relapse, Incarceration,
Dennis
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
4/12/2017
More likely than adults to be diverted to treatment (OR=4.0)
P not the same in both directions
Incarcerated 7%
27% 3%
(46% stable) 5%
12% 7%
20%
24%
10%
Treatment is the most likely path to recovery
26%
7 %
19%
In the
Community
In Recovery
Using
(62% stable)
(75% stable)
To shift to a chronic condition management paradigm it is necessary to start by recognizing that most people are typically cycling through multiple periods of being in the community using, incarceration, treatment and being in the community in recovery for a month or more. The circles in this figure show the average percent staying in each condition between two annual interviews for this same large sample.
1 From the beginning to end of the quarter an average of 39% change status
2,3,4, these arrows show the percent moving along each pathway from one state to another.
5- Notice that the percentages are not the same in both directions.
6- Also notice that the probability of moving from the three states on the left to recovery on the right are not the same --- with treatment being the most likely pathway to recovery over a 3 month period.
Avg of 39% change status each quarter
In Treatment
(48% stable)
More likely than adults to stay 90 days in treatment (OR=1.7)
Source: 2006 CSAT AT data set
Chestnut Health Systems

45. The Cyclical Course of Relapse, Incarceration,
Dennis
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
4/12/2017
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
12%
Community
In Recovery
Using
(62% stable)
27%
(75% stable)
Probability of from Recovery to “Using” (+ bad)
+ Freq. Of Use ( ) - Initial Weeks in Treatment (0.97)
+ Illegal Activity (1.42) - Treatment Received During Quarter (0.50)
+ Age (1.24) Recovery Environment (r)* (0.69)
- Positive Social Peers (r) (0.70)
If we focus on movement between the two most common states
Below are less likely to transition from using to early recovery if they are older or use more.
1. They are more likely to enter early recovery if they are female, non-white, have self efficacy to resist relapse,
and the more treatment they receive during the transition period.
2. Once in recovery, adolescents are more likely to relapse the more they used recently, were involved in illegal activity and are older.
They were less likely to relapse the longer their initial length of treatment, the range of treatment they received during the quarter, and the more positive their recovery environment and positive social peers during the transition period . Where
recovery environment is defined as the 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
positive social periods during transition period is based on the percent in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.
* 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.
Chestnut Health Systems

46. The Cyclical Course of Relapse, Incarceration,
Dennis
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
4/12/2017
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)
The probability of entering and being in treatment 90 days latter goes down with age, but goes up the more adolescents are being urine monitored, self motivated, and the longer they were in a controlled environment in the prior quarter. 7%
In Treatment
(48 v 35% stable)
Source: 2006 CSAT AT data set
Chestnut Health Systems

47. Probability of Going to Using vs. Early “Recovery” (+ good)
Dennis
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adolescents
4/12/2017
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
In Recovery
Using
(62% stable)
(75% stable)
When they come out of treatment adolescents are more likely to relapse the higher their base rate of substance use severity, the number of past month problems and frequency of substance use at the beginning of the quarter.
They are more likely to transition to recovery the higher the total symptoms count (other problems), the more urine testing they received during the transition period and the better their recovery environment and positive social peers.
26%
19%
* 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 Treatment
(48 v 35% stable)
Source: 2006 CSAT AT data set
Chestnut Health Systems

48. Recommendations for Further Developments…
Dennis
4/12/2017
Recommendations for Further Developments…
Evidenced based interventions can come from both research and practice
Evidence based interventions can improve implementation of treatment and treatment outcomes
Practice based evidence can be used to improve outcomes and is of equal importance
Evidenced based interventions and their outcomes can be replicated in practice
Continuing care and is a key determinant of long term outcomes
Chestnut Health Systems