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Implementing Evidenced Based Substance Abuse Services for Adolescents Michael Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL Presentation at the.

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Presentation on theme: "Implementing Evidenced Based Substance Abuse Services for Adolescents Michael Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL Presentation at the."— Presentation transcript:

1 Implementing Evidenced Based Substance Abuse Services for Adolescents Michael Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL Presentation at the “Joint Conference of the Canadian Evaluation Society (CES) and the American Evaluation Association (AEA)”, Toronto, Ontario, Canada, October The content of this presentations The content of this presentations are based on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract using data provided by the following grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888, TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340, TI130022, TI03345, TI012208, TI013323, TI14376, TI14261, TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272, TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678, TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674, TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514, TI15672, TI15478, TI15447, TI15545, TI15671)). several individual 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 720 West Chestnut, Bloomington, IL 61701, phone: (309) , fax: (309) ,

2 Provide a brief introduction on the move to evidenced based practice (ECP) Summarize the recent growth in adolescent substance abuse treatment and research Discuss the infrastructure and organizational changes that are typically required to shift to evidence based practice Review the materials that are currently available to support evidence based practice, Introduce a common data set of adolescent treatment programs using the Global Appraisal of Individual Needs (GAIN) that is being used by CSAT’s adolescent grantees and which has provided data to support the planning of many of recent papers and presentations Goals of this Presentation

3 The field is increasingly facing demands from payers, policymakers, and the public at large for “evidence-based practices (EBP)” which can reliably produce practical and cost-effective interventions, therapies and medications that will – reduce substance use and its negative consequences among those who are abusing or dependent, – reduce the likelihood of relapse for those who are recovering, and – reduce risks for initiating drug use among those not yet using, NIDA Blue Ribbon Panel on Health Services Research (see )www.nida.nih.gov Context

4 Accumulating evidence indicates that most of the theories and approaches that are used within the community of practitioners are unsupported by empirical evidence of effects Various lists of 70 or so “proven” "empirically supported therapies (ESTs) have proven to be relatively infeasible because they have rarely been compared and generally have not been tested with the clinically diverse samples found in community based settings Need for a new method of integrating scientific evidence and the realities of practice is called for. Source: Beutler, 2000 General Behavioral Health Practice

5 People with multiple substance use and multiple co- occurring problems are the norm of severity in practice, but are often excluded from research Individualization of treatment content/duration is the norm in practice, but research based protocols typically involves fixed components/length that are not as appropriate for heterogeneous problems No treatment is not considered a ethical or significant option, practitioner’s are more interested in identifying which of several treatments to use for a given type of patient – but few such studies have been done When research practices have been identified, they are often not adopted because practitioner’s often lack the appropriate materials, training and resources to know when or how to implement best practices Problems and Barriers in SA Tx

6 Randomized Clinical Trials (RCT) are to Evidence Based Practice (EBP) like Self-reports are to Diagnosis They are only as good as the questions asked (and then only if done in a reliable/valid way) They are an efficient and logical place to start But they can be limited or biased and need to be combined with other information Just because the person does not know something (or the RCT has not be done), does not mean it is not so Synthesizing them with other information usually makes them better

7 So what does it mean to move the field towards Evidence Based Practice (EBP)? 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, and long term program planning 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

8 What are the pitfalls of EBP? EBP generally causes some staff turnover EBP often shines a light on staff or work place problems that would otherwise be ignored EBP often impact a wide range of existing procedures and policies – requiring modification and provoking resistance EBP (and most organizational changes) will fail without good senior staff leadership EBP typically require going for more funds from grant or other funders On-going needs assessment will create demand for more change and more EBP

9 Increasing availability and use of standardized assessment to help focus and improve clinical practice Growing number of manualized protocols designed for replication and use in practice CSAT increasingly encouraging and/or requiring the use of standardized assessment, manuals, training, and quality assurance practices to ensure adherence ATTCs collaborating with CSAT, NIDA and NIAAA to train individual staff Growing Literature GAIN/ JMATE workgroups (Gender, Spanish, African American, Asian, LGBT, Juvenile Justice, Comorbidity, Strength Based, Substance-specific, Intervention- specific, Trainers, Data Managers, MIS, Evaluators ) Growing Infrastructure There is a list of above resources at the end of these handouts

10 How we are building a common knowledge base about what is working for whom through Pooling data across multiple evaluations and programs Identifying common factors and principals that appear to hold across interventions Having peer reviewed panels review and rate the strength of evidence on the effectiveness and generalizability of specific interventions Conducting formal meta analysis of a groups of similar interventions that have been replicated and evaluated several times

11 Reoccurring Themes… Severity and specificity of problem subgroup Manualized and replicable protocols Relative strength of intervention for a specific problem Adherence and implementation of intervention Evaluation of outcomes targeted by the intervention (a.k.a., logic modeling)

12 Global Appraisal of Individual Needs (GAIN) The GAIN family of instruments were developed through a 10 year collaboration of researchers, clinicians, policy makers, and IT specialists They provide a standardized approach to measuring: – Eligibility/need (i.e., screening), – DSM/ICD Diagnosis, – ASAM level of care Placement, – Study/State/Federal Reporting, – Treatment Planning, – Severity/Case Mix, – Change in Functioning, Service Utilization, and other Outcomes, and – Economic Cost and Benefits of treatment Includes 103 scales and over 2000 created variables, had good reliability/validity, 174 agencies and over four dozen scientists working with it More information is available at

13 Number of GAIN Sites Adolescent and Adult Treatment Program GAIN Clinical Collaborators 30 to to 29 2 to /05 One or more state or county wide systems uses the GAIN One or more state or county wide systems considering using the GAIN

14 The Current Renaissance of Adolescent Treatment Research NIDA’s Drug Abuse Treatment Outcome Study of Adol. (DATOS-A) Drug Abuse Treatment Outcome Study (DOMS) CSAT’s Cannabis Youth Treatment (CYT) experiments NIAAA/CSAT’s 15 individual research grants CSAT’s 10 Adolescent Treatment Models (ATM) CSAT’s Persistent Effects of Treatment Study (PETS-A) CSAT’s 12 Strengthening Communities for Youth (SCY) RWJF’s 10 Reclaiming Futures (RF) diversion projects CSAT’s 12+ Targeted Capacity Expansion TCE/HIV NIDA’s 14 individual research grants and CTN studies CSAT’s 17 Adolescent Residential Treatment (ART) NIDA’s Criminal Justice Drug Abuse Treatment Study (CJ-DATS) CSAT’s 38 Effective Adolescent Treatment (EAT) NIAAA/CSAT’s study of diffusion of innovation CSAT 22 Young Offender Re-entry Programs (YORP) CSAT 20 Juvenile Drug Court (JDC) CSAT 16 State Adolescent Coordinator (SAC) grants Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN)

15 CSAT AT Program Common Data Set The 2004 CSAT adolescent treatment data set included data on 5,468 adolescents from 67 local evaluations (and is growing exponentially in people, sites, and number of follow-ups) All data collected with the Global Appraisal of Individual Needs (GAIN) using centrally trained and certified staff Outcome data through 12 months available on over 90% of CYT and ATM clients and over 80% of others “due” in on-going programs Programs include several standardized protocols based on both research and practice (ACC, ACRA, ATM, FFT, FSN, Matrix, MET/CBT, MDFT, MST) Local evaluations include several experiments and quasi experiments, as well as up to 40 replications of the same manualized protocol in different sites Several workgroups working on common themes across programs (African American, Co-morbidity, Family, Native American/Indian, Spanish translation/workforce) Data being shared for meta and several secondary analyses

16 CSAT Adolescent Treatment (AT) Programs Reordered by Level of Care and Severity EAT: Effective Adolescent Treatment ( ; n=975) replicating the CYT MET/CBT intervention in early intervention, school and outpatient settings(22 of 36 grants: Bradley, Brown, Clayton,Curry, Davis, Dillon, Dodge, Kressler, Kincaid, Levine, Levy, Locario, Mason, Moore, Rajaee-Moore, Paull, Payton, Rezende, Taylor, Tims, Turner, Vincent) CYT: Cannabis Youth Treatment ( ; n=600) Experiments with adolescent outpatient/intensive outpatient (5 grants: Babor, Dennis, Diamond, Godley, Tims) TCE: Targeted Capacity Expansion ( ; n=189) evaluation of intensive outpatient programs and some residential treatment (2 of 12 grants: Tims, Lloyd) SCY: Strengthening Communities-Youth ( ; n=1120) evaluations of early intervention, outpatient, intensive outpatient and some residential (11 of 12 grants: Beach, Bolland, Dahl, Gerstel, Godley, Hall, Hutchinson, Keehn, Murphy, Noonan, Panzarella) ATM: Adolescent Treatment Model ( ; n=1468) evaluations of outpatient, short and long term residential (10 grants: Batttjes, Fishman, Godley, Liddle, Morral, Perry, Sabin, Shane, Stevens-2) ART: Adolescent Residential Treatment ( ; n=1179) evaluations of residential treatment enhancements and continuing care (17 grants: Beach, Fishman, Flores, Gay, Gnazzo, Hatch, Hurtig, Lane, Law, Manov, May, Miley, Nordquist, Snipes, Urquahart, Whitmore, Zammarelli)

17 Level of Care 0% 20% 40% 60% 80% 100% EAT CYTTCESCY ATMART Total Other Resid. Continuing Care Long Term Residential Med. Term Residential Short Term Residential Intensive Outpatient Outpatient Early Intervention Source: CSAT 2004 AT Common GAIN Data set

18 Gender Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal Male Female While few individual studies can break out females, this data set has 1497 (so far)

19 Race Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal Other Mixed Native American/ Alaskan Hispanic Caucasian/White Asian/Pacific Islander African American Across sites there are 300 or more for all subgroups but Asian (so far)

20 Age Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal Under 14 and 377 young adults

21 Other Characteristics Source: CSAT 2004 AT Common GAIN Data set 50% 39% 34% 86% 70% 45% 0%10%20%30%40%50%60%70%80%90%100% Single Parent Homeless or Runaway Employed In School Juvenile Justice Involvement Recently in a Controlled Environment

22 Years of Use Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal 5+ Years 3-4 Years 1-2 Years Less than 1

23 Substance Use Severity (based on self-report) Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal Dependence Abuse Subclinical use/problems

24 Weekly/Daily Substance Use Pattern Source: CSAT 2004 AT Common GAIN Data set 65% 20% 52% 5% 3% 8% 30% 0%10%20%30%40%50%60%70%80%90%100% Any AOD Use Alcohol Marijuana Cocaine/Crack Heroin/Opioids Other Drugs 14 or more days in Controlled Environment In our data and in TEDS, 1 in 5 did not use in the month before intake – hence the use of 90 day window and measures of pre-CE use

25 Prior Substance Abuse Treatment Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal Two or more One None

26 Mixed Problem Recognition Source: CSAT 2004 AT Common GAIN Data set 35% 81% 92% 99% 0%10%20%30%40%50%60%70%80%90%100% Acknowledges AOD problem Believes treatment needed Self reports meets abuse/dependence criteria Gives one or more reasons to quit

27 High Risk Recovery Environments Source: CSAT 2004 AT Common GAIN Data set 29% 52% 61% 17% 67% 79% 0%10%20%30%40%50%60%70%80%90%100% Regular alcohol use In home among work/ school peers among social peers Regular drug use In home among work/ school peers among social peers

28 Patterns of Co-Occurring Disorders Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal Both Internal & External Disorders External Disorder(s) Only Internal Disorder(s) only Neither

29 Interventions need to be more specific Source: CSAT 2004 AT Common GAIN Data set 49% 38% 21% 28% 32% 28% 67% 59% 48% 0%10%20%30%40%50%60%70%80%90%100% Any Internal Disorder Depressive Disorder Anxiety Disorder Trauma Related Disorder Any Self Mutilation Any homicidal/ suicidal thoughts Any External Disorder Conduct Disorder Attention Deficit-Hyperactivity Disorder (ADHD) Within a diagnosis there are also mild to severe subgroups

30 Also High Rates of HIV/STI risk behaviors Source: CSAT 2004 AT Common GAIN Data set 81% 57% 16% 61% 51% 35% 29% 23% 4% 0%10%20%30%40%50%60%70%80%90%100% Sexual Activity Victimization Needle Use Sexual Activity Sex Under AOD Influence Multiple Sex Partners Unprotected Sex Victimization Needle Use Lifetime Past 90 Days

31 Severity of Victimization History Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal High (4-15 on General Victimization Scale [GVS] *) Moderate (Any Lifetime, 1-3 on GVS*) Low (No History) * Based on lifetime history and current fear of 4 types of victimization (attached with a weapon, beaten, sexually assaulted, emotionally abused), and 8 trauma factors (under 18, someone trusted, multiple people, multiple times, sexual penetration, fear for life, no one believed when reported)

32 Victimization interacts with MH problems Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% LowModerateHighTotal Both Internal & External Disorders External Disorder(s) Only Internal Disorder(s) only Neither  Severity of Victimization 

33 Intensity of Juvenile Justice System Involvement Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal In detention/ jail 14+ days On prob./ parole 14+ days w/ 1+ drug screens Other probation, parole, detention Other JJ status Past arrest/ JJ status Past year illegal activity/SA use

34 It is NOT just about possession… Source: CSAT 2004 AT Common GAIN Data set 86% 72% 58% 57% 51% 0%10%20%30%40%50%60%70%80%90%100% Any violence or illegal activity Physical Violence Property Crimes Drug Related Crime Interpersonal Crimes Past Year

35 Need to focus on multiple problems clients Source: CSAT 2004 AT Common GAIN Data set 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% EATCYTTCESCYATMARTTotal 5 or more Problems 4 Problems 3 Problems 2 Problems 1 Problem Number of 12 Major Clinical Problems* * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Generalizability of research focused on a single problem

36 Victimization is particularly intertwined with the number of problems* Source: CSAT 2004 AT Common GAIN Data set (odds for High over odds for Low) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 Problem 2 Problems3 Problems 4 Problems5 or more Problems (117.2) LowMod.High * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

37 Victimization Also Interacts with 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 OP Both groups respond to residential treatment

38 How do CHS OP’s high GVS outcomes compare with other OP programs on average? Source: CYT and ATM Outpatient Data Set IntakeMon 1-3Mon 4-6Mon 7-9Mon Z-Score on Substance Frequency Scale (SFS) CYT Total (n=217; d=0.51) ATM Total (n=284; d=0.41) CHSOP (n=57; d=0.18) Other programs serve clients who have significantly higher severity And on average they have moderate effect sizes even with high GVS Green line is CHS OP’s High GVS adolescents; they have some initial gains but substantial relapse

39 Which 5 OP programs did the best with high GVS adolescents? Source: CYT and ATM Outpatient Data Set IntakeMon 1-3Mon 4-6Mon 7-9Mon Z-Score on Substance Frequency Scale (SFS) 7 Challenges (n=42; d=1.21) Tucson Drug Court (n=27; d=0.65) MET/CBT5a (n=34; d=0.62) MET/CBT5b (n=40; d=0.55) FSN/MET/CBT12 (n=34; d=0.53) CHSOP (n=57; d=0.18) The two best were used with much higher severity adolescents and TDC was not manualized Next we can check to see if they are any more similar in severity

40 IntakeMon 1-3Mon 4-6Mon 7-9Mon Z-Score on Substance Frequency Scale (SFS) MET/CBT5a (n=34; d=0.62) MET/CBT5b (n=40; d=0.55) FSN/MET/CBT12 (n=34; d=0.53) Epoch (n=72; d=0.33) TSAT (n=66; d=0.35) CHSOP (n=57; d=0.18) Which 5 OP Programs, of similar severity, did the best with high GVS adolescents? Source: CYT and ATM Outpatient Data Set Trying MET/CBT5 because it is stronger, cheaper, and easier to implement Not much improvement and they do not work quite as well Currently CHS is doing an experiment comparing its regular OP with MET/CBT5

41 Areas where staff wanted more specific knowledge and interventions Victimization, trauma and helplessness Self mutilation, para-suicidal and suicidal behaviors Anger management, violence and crime How to help their kids access mental health services (typically for internal disorders) when availability is limited Managing ADHD and impulsivity How to get parents involved in treatment and continuing care Tobacco, opioids, and methamphetamine use, Working with schools, probation, families Females, Males, African Americans, Native Americans, Spanish Speaking adolescents and their families HIV, STI, and Liver risk How to make interventions more assertive and strength based Evaluation issues like follow-up, data management, & analysis Workforce development, including peer-to-peer on specific treatment approaches and other job functions like MIS

42 Common Strategies you can do NOW Standardize assessment and identify most common problems Pool knowledge about what staff have done in the past, whether it worked, and what the barriers were Identify system barriers (e.g., criteria to local access case management, mental health) that could be avoided if thought of in advance Identify existing materials that could help and make sure they are readily available on site Identify promising strategies for working with the adolescent, parents, or other providers Develop a 1-2 page checklist of things to do when this problem comes up Identify a more detailed protocol and trainer to address the problem, then go for a grant to support implementation

43 Resources Assessment Instruments – CSAT TIP 3 at – NIAAA Assessment Handbook,http://www.niaaa.nih.gov/publications/instable.htm – GAIN Coordinating Center Treatment Programs – CSAT CYT, ATM, ACC and other treatment manuals at or – SAMHSA at or NCADI at – National Registry of Effective Prevention Programs Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services :

44 Resources Implementing Evidenced based practice – Central East ATTC Evidence Based Practice Resource Page – Northwest Frontier ATTC Best Practices in Addiction Treatment: A Workshop Facilitator's Guide – Turning Knowledge into Practice: A Manual for Behavioral Health Administrators and Practitioners About Understanding and Implementing Evidence-Based Practices – Evidence-Based Practices: An Implementation Guide for Community- Based Substance Abuse Treatment Agencies – National Center for Mental Health and Juvenile Justice Evidence Based Practice resource list at – 2005 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness – Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE)

45 References Cited Here Beutler, L. E. (2000). David and Goliath When empirical and clinical standards of practice meet. American Psychologist, 55, Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28 (2S), S49-S60. Dennis, M.L., & White, M.K. (2003). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through 2001, (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems. [On line] Available at Dennis, M. L. and White, M. K. (2004). Predicting residential placement, relapse, and recidivism among adolescents with the GAIN. Poster presentation for SAMHSA's Center for Substance Abuse Treatment (CSAT) Adolescent Treatment Grantee Meeting; Feb 24; Baltimore, MD Feb. White, M. K., Funk, R., White, W., & Dennis, M. (2003). Predicting violent behavior in adolescent cannabis users The GAIN-CVI. Offender Substance Abuse Report, 3(5), White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2),


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