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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,

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Presentation on theme: "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,"— Presentation transcript:

1 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) ,

2 2 1.Examine the prevalence, course, and consequences of adolescent substance use, co- occurring disorders and the unmet need for treatment overall 2.Summarize major trends in the adolescent treatment system and Pennsylvania 3.Highlight what it takes to move the field towards evidenced-based practice related to assessment, treatment, program evaluation and planning 4.Present the findings from several recent treatment studies on substance abuse treatment research, trauma and violence/crime Goals of this Presentation are to

3 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% Light Alcohol Use Only 47% No Alcohol or Drug Use 32% Source: 2002 NSDUH

4 4 Problems Vary by Age Source: 2002 NSDUH and Dennis et al forthcoming 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

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

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

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

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

11 11 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

12 12 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

13 13 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

14 14 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

15 15 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

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

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

18 18 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 Despite being widely recommended, only 10% step down after intensive treatment

19 19 Past Year Alcohol or Drug Abuse or Dependence Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH 8.8% PA vs. 8.9% National

20 20 Adolescent SUD & Treatment Still less than 1 in 15 get treatment Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

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

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

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

24 24 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

25 25 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

26 26 Major Predictors of Bigger Effects 1. Chose a strong intervention protocol based on prior evidence 2. Used quality assurance to ensure protocol adherence and project implementation 3. Used proactive case supervision of individual 4. Used triage to focus on the highest severity subgroup

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

28 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 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

29 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 30 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

31 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 32 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

33 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 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 35 GAIN Clinical Collaborators Adolescent and Adult Treatment Program 10/07 GAIN State System Virgin Islands 0 1 to to to 130 Indiana Kansas Maine Montana Nebraska Nevada North Dakota Puerto Rico Hawaii New Mexico South Dakota Alabama Arkansas Iowa Oklahoma Rhode Island South Carolina District Of Columbia Tennessee Utah Louisiana W. Virginia Minnesota Wisconsin New Jersey North Carolina Alaska Delaware Maryland Pennsylvania Georgia Kentucky Virginia Michigan New York Oregon Colorado Texas New Hampshire Connecticut Illinois Missouri Arizona Florida Ohio Vermont Idaho Massachusetts California Washington Wyoming GAIN-SS State or County System Number of GAIN Sites Mississippi

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

37 37 Substance Use Problems Source: CSAT 2007 AT Outcome Data Set (n=12,601)

38 38 Past 90 day HIV Risk Behaviors Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

39 39 Co-Occurring Psychiatric Problems Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

40 40 Past Year Violence & Crime *Dealing, manufacturing, prostitution, gambling (does not include simple possession or use) Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

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

42 42 Number of Problems by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

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

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: 2006 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 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) 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% Source: 2006 CSAT AT data set 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

47 47 In the Community Using (75% stable) In Treatment (48 v 35% stable) In Recovery (62% stable) Source: 2006 CSAT AT data set 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.

48 48 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


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