1. Advances in Adolescent Substance Abuse Treatment and Research Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL Presentation for the Young Offender Re-Entry Program (YORP) and Targeted Capacity Expansion (TCE) Grantee Kick Off Meeting, December 6-8 2004, Crystal City, VA. Sponsored by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270-2003-00006. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/li/apss or from the author at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: Mdennis@Chestnut.Org

2. Examine the prevalence, course, and consequences of adolescent substance use and co-occurring disorders Summarize major trends in the adolescent treatment system Review the current knowledge base on treatment effectiveness Examine the results of three recent major studies Examine how characteristics vary by intensity of juvenile justice system involvement Goals of this Presentation

3. Relationship between Past Month Substance Use and Age Source: Dennis (2002) and 1998 NHSDA.

4. Age of First Use Predicts Dependence an Average of 22 years Later Source: Dennis,Babor, Roebuck & Donaldson (2002) and 1998 NHSDA

5. Source: OAS (2004). Results from the 2003 National Survey on Drug Use and Health: National Findings. Rockville, MD: SAMHSA. http://oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.pdf The Growing Incidence of Adolescent Marijuana Use: 1965-2002 Adult Initiation Relatively Stable Adolescent Initiation Rising

6. Importance of Perceived Risk Source: Office of Applied Studies. (2000). 1998 NHSDA Marijuana Use Risk & Availability

7. Actual Marijuana Risk From 1980 to 1997 the potency of marijuana in federal drug seizures increased three fold. The combination of alcohol and marijuana has become very common and appears to be synergistic and leads to much higher rates of problems than would be expected from either alone. Combined marijuana and alcohol users are 4 to 47 times more likely than non-users to have a wide range of dependence, behavioral, school, health and legal problems. Marijuana and alcohol are the leading substances mentioned in arrests, emergency room admissions, autopsies, and treatment admissions.

8. Source: Dennis and McGeary (1999) and 1997 NHSDA Substance Use in the Community

9. Consequences of Substance Use Source: Dennis, Godley and Titus (1999) and 1997 NHSDA.

10. Source: D. Wright (2004). State Estimates of Substance Use from the 2002 National Survey on Drug Use and Health, Rockville, MD: OAS, SAMHSA. http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf Adolescents with Past Year Alcohol or Other Drug (AOD) Abuse or Dependence National=8.92%

11. Adolescents Needing But Not Receiving Treatment for Alcohol Use Source: D. Wright (2004). State Estimates of Substance Use from the 2002 National Survey on Drug Use and Health, Rockville, MD: OAS, SAMHSA. http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf National=5.55%

12. Source: D. Wright (2004). State Estimates of Substance Use from the 2002 National Survey on Drug Use and Health, Rockville, MD: OAS, SAMHSA. http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf Adolescents Needing But Not Receiving Treatment for Illicit Drug Use National=5.14%

13. Adolescent Treatment Admissions have increased by 50% over the past decade Source: Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm 50% higher than in 1992

14. Change in Primary Substance Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA. http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf +317% increase in marijuana -50% decrease in alcohol +375% increase in stimulants -21% decrease in cocaine +144% increase in opiates

15. Change in Referral Sources Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA. http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf JJ referrals have doubled and are driving growth

16. Primary Substance by Referral Source Source: OAS 2004, Treatment Episode Data Set (TEDS) 1992-2002. Rockville, MD: SAMHSA. http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf More recent marijuana referrals driven more by JJ

17. Level of Care at Admission Intensive Outpatient 11% Detox. or Hospital 5% Short-Term Residential 6% Long-Term Residential 9% Outpatient 68% Source: Dennis, Dawud-Noursi, Muck & McDermeit, 2002 and 1998 Treatment Episode Data Set (TEDS) Most Adolescents are treated in Outpatient Settings

18. Severity Varies by Level of Care 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Weekly use at intake DependenceFirst used under age 15 Prior Treatment Outpatient (n=24704) Intensive Outpatient (n=4024) Detoxification or Hospital (n=2062) Short Term Residential (n=2046) Long Term Residential (n=3124) Source: Dennis, Dawud-Noursi, Muck & McDermeit, 2002 and 1998 Treatment Episode Data Set (TEDS) Severity goes up with level of care STR clients get there younger and sooner * Weekly use is the Norm * 1 in 5 report with no past month use

19. Key Problems in the System Less than 1/10th of adolescents with substance dependence problems receive treatment Less than 50% stay 6 weeks Less than 75% stay the 3 months recommended by NIDA Under 25% in Residential Treatment successfully step down to outpatient care Little is known about the rate of initiation after detention Source: Dennis, Dawud-Noursi, Muck, & McDermeit (Ives), 2002; Godley et al., 2002; Hser et al., 2001; OAS, 2000

20. Pre-2002 Knowledge Base from 36 Studies 9 large multi-site longitudinal studies (ATM, DARP, TOPS, SROS, TCA, NTIES, DATOS-A, DOMS), including 1 large multi-site experiment (Cannabis Youth Treatment - CYT) 24 behavioral treatment studies (12-step, behavioral, family, other outpatient, inpatient, therapeutic communities, engagement, aftercare), including CYT and 1 pharmacology- behavioral (CBT) trial 8 pharmacology treatment studies (bupropion, disulfiram, fluoxetine, lithium, pemoline, sertaline) and 1 pharmacology- behavioral (CBT) trial Source: Bukstein & Kithas, 2002; Dennis & White (2003), & Lewinsohn et al. 1993; PNLDP, 2003

21. Key Lessons from Early Literature Assessment needs to be very concrete Multiple co-occurring problems are the norm in clinical samples of SUD adolescents (60-80% external disorders, 25-60% mood disorders, 16-45% anxiety disorders, 70-90% 3 or more diagnoses) Adolescents are involved in multiple systems competing to control their behavior (e.g, family, peers, school, work, criminal justice, and controlled environments) Relapse is common in the first 3-12 months Recovery often takes multiple attempts and episodes of care that may take years Improvements generally came during active treatment and were sustained for 12 or more months Family therapies were associated with less initial change but more change post active treatment and less relapse

22. Interventions associated with reduced substance use and problems: 1 experimental and 3 non-experimental studies of 12-step treatment (e.g., CD, Hazelden) 7 experimental studies of behavior therapies (e.g., ACRA, AGT, BTOS, CBT, MET, RP) 8 experimental studies of family therapy (CFT, FDE, FFT, FSN, FST, MDFT, MST, PBFT, TIPS) 6 longitudinal studies of existing outpatient 6 longitudinal studies of existing short term residential/inpatient 7 longitudinal studies of therapeutic communities (TC) and other forms of long term residential treatment (LTR) Another 3 experimental studies have shown that engagement and retention are associated with several interventions (case management, stepping down residential to OP, assertive aftercare)

23. Lessons from 9 Pharmacology Studies No controlled trials of medication for treating withdrawal, substitution therapy, blocking therapy, aversive therapy or management of cravings – Though NIDA’s Clinical Trials Network (CTN) and Australian researchers are currently studying the effects of Buprenorphine/Naloxone Most studies of other disorders exclude adolescents with substance use disorders Small (n of 8-25), short-term (4-12 weeks) studies suggest medication can be used to effectively treat several co- occurring problems: – Fluoxetine (Prozac®) & Sertaline (Zoloft®) helped reduce depressive symptoms – Lithium carbonate (Eskalith®) reduced bipolar symptoms and positive urine rates – Pemoline (Cylert®) and Bupropion (Wellbutrin®) reduced symptoms of ADHD

24. Effectiveness was also associated with therapies that technologically were: manual-guided had developmentally appropriate materials involved more quality assurance and clinical supervision achieved therapeutic alliance and early positive outcomes successfully engaged adolescents in aftercare, support groups, positive peer reference groups, more supportive recovery environments

25. Lessons about What did NOT work Interventions associated with No or Minimal Change: Passive referrals Educational units alone Probation services as usual Early unstandardized outpatient services as usual Interventions associated with deterioration: treatment of adolescents in badly managed groups or “groups including one or more highly deviant individuals” (but NOT! all groups or any CD) treatment of adolescents in adult units and/or with adult models/materials (particularly outpatient)

26. Key Points that Have Been Contentious As other therapies have improved, there is no longer the clear advantage of family therapy found in early literature reviews While there have been concerns about the potential iatrogenic effects of group therapy, the rates do not appear to be appreciably different from individual or family therapy if it is done well (important since group tx typically costs less) Effectiveness was not consistently associated with the amount of therapy over a short period of time (6-12 weeks) but was related to longer term continuing care Over time, adolescents regularly cycle between use, treatment, incarceration and recovery Treatment primarily impacts the short term movement from use to non use in the community The long term effectiveness of therapy was dependent on changes in the the long term recovery environment and social risk

27. Limitations of the Early Literature Small sample sizes (most under 50) High rates (30-50%) of refusals by eligible people Unstandardized measures, no measures of abuse or dependence, no measures of co-morbidity, crime or violence (just arrest) Unstandardized and minimally-supervised therapies (making replication very difficult) Minimal information on services received High rates (20-50%) of treatment dropout High rates of attrition from follow-up (25-54%) leading to potentially large (unknown) bias

28. Studies are Improving! New studies are likely to have higher rates of participation (70-90%), treatment completion (70-85%), and successful follow-up (85-95%) They are more likely to involve standardized assessments, manual-guided therapy, and better quality assurance/clinical supervision Have experimental design, multiple time points of assessment and follow-up lasting 1 or more years Include economic analysis of their costs, cost-effectiveness and benefit cost Have agreed to pool their data to facilitate further comparisons and secondary analysis

29. Studies by Date of First Publication From 1998 to 2002 the number of adolescent treatment studies doubled and has doubled again in the past 2 years – with twice this many published in the past 2 years and over 100 adolescent treatment studies currently in the field Source: Dennis &, White (2003) at www.drugstrategies.org.

30. Studies with Publications Currently Coming Out 1994-2000 NIDA’s Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A) 1995-1997 Drug Abuse Treatment Outcome Study (DOMS) 1997-2000 CSAT’s Cannabis Youth Treatment (CYT) experiments 1998-2003 NIAAA/CSAT’s 14 individual research grants 1998-2003 CSAT’s 10 Adolescent Treatment Models (ATM) 2000-2003 CSAT’s Persistent Effects of Treatment Study (PETS-A) 2002-2007 CSAT’s 12 Strengthening Communities for Youth (SCY) 2002-2007 RWJF’s 10 Reclaiming Futures (RF) diversion projects 2002-2007 CSAT’s 12+ Targeted Capacity Expansion TCE/HIV 2003-2009 NIDA’s 12 individual research grants 2003-2006 CSAT’s 17 Adolescent Residential Treatment (ART) 2003-2008 NIDA’s Criminal Justice Drug Abuse Treatment Study (CJ-DATS) 2003-2007 CSAT’s 36 Effective Adolescent Treatment (EAT) 2004-2007 NIAAA/CSAT’s study of diffusion of innovation Full ( ) or Partial ( ) use of the Global Appraisal of Individual Needs (GAIN)

31. Source: www.chestnut.org/li/apss NIAAA/NIDA Other Grantees CSAT Cannabis Youth Treatment (CYT) Adolescent Treatment Model (ATM) Strengthening Communities for Youth (SCY) Adolescent Residential Treatment (ART) Effective Adolescent Treatment (EAT) Targeted Capacity Expansion (TCE) grants Other Collaborators RWJF Reclaiming Futures Program Other RWJF Grantees Other Grants/Contracts Co-occurring Disorder Studies Young Offender Re-Entry Program (YORP) Adolescent Treatment Program GAIN Clinical Collaborators State or County-wide System (also negotiating with 6 state/counties)

32. Since 1997, the data has been pooled to create one of the largest benchmark data sets in the field 17,464 32,054 57,360 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 Cumulative GAIN Interviews (observations) Prior to FY2003 FY2004FY2005 FY2006 Largest Combined Adolescent Data Set ~ Half of all Adolescent Treatment Data One of the Largest Data Sets in the Field with 1+ year follow-up (2 nd only to ASI) 74,670..and we are still growing

33. Findings from 3 Recent Adolescent Treatment Studies CSAT’s Cannabis Youth Treatment (CYT) Experiments with 5 treatment models CSAT’s 10 Adolescent Treatment Model (ATM) grants NIAAA’s Assertive Continuing Care (ACC) experiment All have public domain manuals*, used the GAIN, have good adherence, retention, and follow-up *see http://www.chestnut.org/li/apss/CSAT/protocols

34. CYT Cannabis Youth Treatment Randomized Field Trial Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services Coordinating Center: Chestnut Health Systems, Bloomington, IL, and Chicago, IL University of Miami, Miami, FL University of Conn. Health Center, Farmington, CT Sites: Univ. of Conn. Health Center, Farmington, CT Operation PAR, St. Petersburg, FL Chestnut Health Systems, Madison County, IL Children’s Hosp. of Philadelphia, Phil.,PA

35. Randomly Assigns to: MET/CBT5 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) MET/CBT12 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (12 weeks) FSN Family Support Network Plus MET/CBT12 (12 weeks) Trial 2Trial 1 Incremental ArmAlternative Arm Two Effectiveness Experiments ACRA Adolescent Community Reinforcement Approach(12 weeks) MDFT Multidimensional Family Therapy Randomly Assigns to: MET/CBT5 Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) (12 weeks) Source: Dennis et al, 2002

36. Contrast of the Treatment Structures Individual Adolescent Sessions CBT Group Sessions Individual Parent Sessions Family Sessions/Home Visits Parent Education Sessions Total Formal Sessions Type of Service MET/ CBT5 MET/ CBT12 FSNACRAMDFT 2 3 5 2 10 12 2 10 4 6 22 10 2 2 14 6 3 6 15 Case management/ Other Contacts As needed Total Expected Contacts51222+14+15+ Total Expected Hours51222+14+15+ Total Expected Weeks6-712-13 Source: Diamond et al, 2002

37. Actual Treatment Received by Condition Source: Dennis et al, 2004 MET/CBT12 adds 7 more sessions of group FSN adds multi family group, family home visits and more case management ACRA and MDFT both rely on individual, family and case management instead of group With ACRA using more individual therapy And MDFT using more family therapy

38. $1,559 $1,413 $1,984 $3,322 $1,197 $1,126 $- $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 MET/CBT5 (6.8 weeks) MET/CBT12 (13.4 weeks) FSN (14.2 weeks w/family) MET/CBT5 (6.5 weeks) ACRA (12.8 weeks) MDFT(13.2 weeks w/family) $1,776 $3,495 NTIES Est (6.7 weeks) NTIES Est.(13.1 weeks) Average Cost Per Client-Episode of Care |--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----| Average Episode Cost ($US) of Treatment Source: French et al., 2002 Less than average for 6 weeks Less than average for 12 weeks

39. Implementation of Evaluation Over 85% of eligible families agreed to participate Quarterly follow-up of 94 to 98% of the adolescents from 3- to 12-months (88% all five interviews) Collateral interviews were obtained at intake, 3- and 6- months on over 92-100% of the adolescents interviewed Urine test data were obtained at intake, 3, 6, 30 and 42 months 90-100% of the adolescents who were not incarcerated or interviewed by phone (85% or more of all adolescents). Long term follow-up completed on 90% at 30-months Self reported marijuana use largely in agreement with urine test at 30 months (13.8% false negative, kappa=.63) 5 treatment manuals drafted, field tested, revised, send out for field review, and finalized (10-30,000 copies of each already printed and distributed) Descriptive, outcome and economic analyses completed Source: Dennis et al, 2002, 2004

40. Adolescent Cannabis Users in CYT were as or More Severe Than Those in TEDS* Source: Tims et al, 2002

41. Demographic Characteristics Source: Tims et al, 2002

42. Institutional Involvement 25% 87% 47% 62% 0% 20% 40% 60% 80% 100% In schoolEmployedCurrent JJ Involvement Coming from Controlled Environment Source: Tims et al, 2002

43. Patterns of Substance Use 9% 17% 71% 73% 0% 20% 40% 60% 80% 100% Weekly Tobacco Use Weekly Cannabis Use Weekly Alcohol Use Significant Time in Controlled Environment Source: Tims et al, 2002

44. Multiple Problems were the NORM Self-Reported in Past Year Source: Dennis et al, 2004

45. Substance Use Severity was Related to Other Problems * p<.05 Source: Tims et al 2002

46. CYT Increased Days Abstinent and Percent in Recovery (no use or problems while in community) Source: Dennis et al., 2004 0 10 20 30 40 50 60 70 80 90 Intake36912 Days Abstinent Per Quarter 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% % in Recovery at the End of the Quarter Days Abstinent Percent in Recovery

47. Similarity of Clinical Outcomes by Conditions Source: Dennis et al., 2004 200 220 240 260 280 300 Total days abstinent. over 12 months 0% 10% 20% 30% 40% 50% Percent in Recovery. at Month 12 Total Days Abstinent* 269256260251265257 Percent in Recovery** 0.280.170.220.230.340.19 MET/ CBT5 (n=102) MET/ CBT12 FSN (n=102) MET/ CBT5 (n=99) ACRA (n=100) MDFT (n=99) Trial 1 Trial 2 * n.s.d. effect size f=0.06 ** p<.05, effect size f=0.12 * n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16

48. Moderate to large differences in Cost-Effectiveness by Condition Source: Dennis et al., 2004 $0 $4 $8 $12 $16 $20 Cost per day of abstinence over 12 months $0 $4,000 $8,000 $12,000 $16,000 $20,000 Cost per person in recovery at month 12 CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38 CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 MET/ CBT5 MET/ CBT12 FSN MET/ CBT5 ACRA MDFT * p<.05 effect size f=0.48 ** p<.05, effect size f=0.72 Trial 1 Trial 2 * p<.05 effect size f=0.22 ** p<.05, effect size f=0.78 MET/CBT5 and 12 did better than FSN ACRA did better than MET/CBT5, and both did better than MDFT

49. Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition Source: Dennis et al., 2003; forthcoming $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 CPPR at 30 months** $6,437 $10,405 $24,725 $27,109 $8,257 $14,222 CPPR at 12 months* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 MET/ CBT5MET/ CBT12FSNMMET/ CBT5ACRAMDFT Trial 1 (n=299)Trial 2 (n=297) Cost Per Person in Recovery (CPPR) * P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months ** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months Stability of MET/CBT-5 findings mixed at 30 months MET/CBT-5, -12 and ACRA more cost effective at 12 months Integrated family therapy (MDFT) was more cost effective than adding it on top of treatment (FSN) at 30 months ACRA Effect Largely Sustained

50. 12 and 30 month Reductions in the Costs to Society offset the cost of treatment (by site) Source: French et al, 2003; Dennis et al forthcoming Includes the cost of CYT Treatment Cost of Treatment offset within 6 to 30 months

51. 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 Source: Dennis et al forthcoming

52. AOD Use for 5 Relapse Trajectory Groups 0 10 20 30 40 50 60 70 80 90 3691230 Wave Average Days Low AOD (n=171) Low AOD/Hi CE (n=104) Dec/Mod AOD Use (n=116) Inc AOD (n=130) Hi AOD (n=42) Source: Godley et al 2004

53. Environmental Factors were the Main Predictor of Relapse/Continued Use Recovery Environment Risk Social Risk Family Conflict Family Cohesion Social Support Substance Use Substance- Related Problems Baseline.32.18 -.13.21 -.08.32.19.22.32.22.17.11.43.77 (R-square).82.74.58 -.54 -.09.19 Source: Godley et al (in press) For Months 3 to 12 CFI=.97 to.99, RMSEA=.04 to.06

55. Key Adaptation for Adolescents Examples need to be altered to relevant substances, situations, and triggers Consequences have to be altered to things of concern to adolescents Most adolescents do not recognize their substance use as a problem and are being mandated to treatment All materials need to be converted from abstract to concrete concepts Co-morbid problems (mental, trauma, legal) are the norm and often predate substance use Treatment has to take into account the multiple systems (family, school, welfare, criminal justice) Less control of life and recovery environment Less aftercare and social support Complicated staffing needs

56. Length of Stay Varies by Level of Care Source: Adolescent Treatment Model Data

57. Adolescents often go through multiple levels of care Source: Adolescent Treatment Model Data Length of Stay Across Episodes of care is about 50% longer

58. Program Evaluation Data Level of CareClinicsAdolescents1+ FU* Outpatient/ Intensive Outpatient (OP/IOP) 856096% Long Term Residential (LTR)**439098% Short Term Residential (STR)** 459497% Total16154497% * Completed follow-up calculated as 1+ interviews over those due-done, with site varying between 2-4 planned follow-up interviews. Of those due and alive, 89% completed with 2+ follow-ups, 88% completed 3+ and 78% completed 4. ** Both LTR and STR include programs using CD and therapeutic community models

59. Years of Use Source: Adolescent Treatment Model (ATM) data

60. Patterns of Weekly (13+/90) Use Source: Adolescent Treatment Model (ATM) data 61 71 83 56 57 72 20 29 43 4 7 14 1 4 9 0 20 40 60 80 100 OP/IOP (n=560)LTR (n=390)STR (n=594) Weekly use of anythingWeekly Marijuana Use Weekly Alcohol UseWeekly Crack/Cocaine Use Weekly Heroin/Opioid Use 7 21 17 Weekly Other Drug Use 29 44 41 13+ Days in Controlled Environment

61. Substance Use Severity Source: Adolescent Treatment Model (ATM) data

62. Change in Substance Frequency Index by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

63. Change in Substance Problem Index by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

64. Percent in Recovery (no past month use or problems while living in the community) \a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

65. Multiple Co-occurring Problems Were the Norm and Increased with Level of Care Source: CSAT’s Cannabis Youth Treatment (CYT) and Adolescent Treatment Model (ATM), 44 21 25 21 70 47 43 78 80 65 88 56 36 35 68 44 52 0 20 40 60 80 100 Conduct Disorder ADHDMajor Depressive Disorder Generalized Anxiety Disorder Traumatic Stress Disorder Any Co- Occurring Disorder OutpatientLong Term ResidentialShort Term Residential

66. Change in Emotional Problem Index by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

67. Pattern of SA Outcomes is Related to the Pattern of Psychiatric Multi-morbidity Source: Shane et al 2003, PETSA data Months Post Intake (Residential only) 0 3 6 12 Number of Past Month Substance Problems 2+ Co-occurring 1 Co-occurring No Co-occurring Multi-morbid Adolescents start the highest, change the most, and relapse the most

68. High Rates of Victimization are the Norm Source: Adolescent Treatment Model (ATM) data

69. Victimization is Related to Severity Source: Titus, Dennis, et al., 2003

70. Victimization Also Interacts with Level of Care to Predict SA Outcomes Source: Funk, et al., 2003 0 5 10 15 20 25 30 35 40 Intake6 MonthsIntake6 Months Marijuana Use (Days of 90) OP -AcuteOP - Low/Cl.Resid-AcuteResid - Low/Cl. Outpatient Residential Traumatized groups have higher severity Acute trauma group does not respond to OP Both groups respond to residential treatment

71. Broad Range of Past Year Illegal Activity Source: Adolescent Treatment Model (ATM) data

72. Change in Illegal Activity Index by Level of Care\a \a Source: Adolescent Treatment Model (ATM) data; Level of cares coded as Long Term Residential (LTR, n=390), Short Term Residential (STR, n=594), Outpatient/Intensive and Outpatient (OP/IOP, n=560);. T scores are normalized on the ATM outpatient intake mean and standard deviation. Significance (p<.05) marked as \t for time effect, \s for site effect, and \ts for time x site effect.

73. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Low (n=150)Moderate (n=158)High (n=216) No crime Incarcerated Substance Use only Non-violent crime Violent crime X2(8)=18.36, p<.05 GAIN’s Crime and Violence Scale at Intake can predict 30 Months Recidivism Odds of committing violent crime 4.5 times higher Source: White et al (2003), PETSA

74. Crime/Violence and Substance Problems Interact to Predict Recidivism Low Mod. High Low Mod. High 0% 20% 40% 60% 80% 100% Substance Problem Scale (Abuse/Dependence symptoms) Crime and Violence Scale Source: Dennis et al 2004 Probability of 12 month recidivism The probability of committing another crime goes up with the CVS score The probability of committing another crime goes up with the SPS score Knowing both is the best predictor

75. Findings from the Assertive Continuing Care (ACC) Experiment 183 adolescents admitted to residential substance abuse treatment Treated for 30-90 days inpatient, then discharged to outpatient treatment Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC) Source: Godley et al 2002

76. Assertive Continuing Care (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)

77. Usual Continuing Care (UCC): Expectation vs. Performance Source: Godley et al 2002 0% 10% 20% 30%40%50%60%70%80%90%100% Expected 0% 10% 20% 30%40%50%60%70%80%90%100% Expected WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/probation/school Follow up on referrals 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 8/12 criteria UCC

78. Results: Improved Adherence Source: Godley et al 2002 ACC * p<.05 0% 10% 20% 30% 40%50%60%70%80%90% 100% WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/probation/school Follow up on referrals* 0% 10% 20% 30% 40%50%60%70%80%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 8/12 criteria* UCC

79. Reduced Relapse: Marijuana Source: Godley et al 2002; forthcoming Days to First Alcohol Use (p<.05) Percent Remaining Abstinent UCC ACC

80. Reduced Relapse: Alcohol Source: Godley et al 2002, forthcoming Days to First Alcohol Use (p<.05) Percent Remaining Abstinent ACC UCC

81. Secondary Analysis by Intensity of Juvenile Justice System Involvement 0%10%20%30%40%50%60%70%80%90% 100% Severity Detention 14+ days (n=433) Probation/parole and urine monitoring 14+ days (n=472) Other current arrest or JJ status (n=303) Other detention, parole, or probation (n=374) Past arrest or JJ status (n=170) Past year illegal activity (n=298) Source: CYT & ATM Data Low Hi

82. Intensity by Level of Care 0%10%20%30%40%50%60%70%80%90%100% Short Term Residential Long Term Residential Outpatient/IOP Step Down OP Total Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data

83. Intensity by Demographics Detention 14+ days (n=433)Probation/parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Female Caucasian African American Hispanic Native American Other Females and Caucasians more likely in lower intensity Minorities More Likely to be in higher intensity

84. Intensity by Demographics (continued) Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data High Severity More likely to be 15-17 years olds and from Single Parent Families Low Intensity More Likely to be Still Committing Crime

85. Intensity by Substance Use Disorder Diagnosis Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data; a\ Self report for past year Current Intensity Inversely related to Substance Use Severity Past Involvement a Mix of Severity

86. Intensity by External Diagnoses Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data

87. Intensity by Internal Diagnoses/Problems Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data \b n=1838 because some sites did not ask trauma questions Curvilinear Relationship between Intensity and Internal Distress

88. Intensity by Pattern of Co-occurring Disorders Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data Most Internal Distress is Multi- morbid with External (and Substance Use) Disorders

89. Intensity by Other Common Problems Detention 14+ days (n=433)Probation/ Parole and urine monitoring 14+ days (n=472) Other detention, parole, or probation (n=374)Other current arrest or JJ status (n=303) Past arrest or JJ status (n=170)Past year illegal activity (n=298) Source: CYT & ATM Data 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any Victimization High levels of Victimization Any crimeHigh Crime/ Violence Homeless or Runaway High Health Problems Focus of JJ Detention

90. Concluding Comments We are entering a renaissance of new knowledge in this area, but are only reaching 1 of 10 in need Several interventions work, but 2/3 of the adolescents are still having problems 12 months later We need to move beyond focusing on minor variations in therapy (behavioral brand names) and acute episodes of care to focus on continuing care and a recovery management paradigm It is very difficult to predict exactly who will relapse so it is essential to conduct aftercare monitoring with all adolescents Juvenile justice referrals are a central factor in recent growth of the adolescent treatment system and the intensity of JJ involvement is correlated with clinical severity

91. Resources Copy of these slides and handouts – http://www.chestnut.org/LI/Posters/ Assessment Instruments – CSAT TIP 3 at http://www.athealth.com/practitioner/ceduc/health_tip31k.html – NIAAA Assessment Handbook,http://www.niaaa.nih.gov/publications/instable.htm – GAIN Coordinating Center www.chestnut.org/li/gain Adolescent Treatment Manuals – CSAT CYT, ATM, ACC and other manuals at www.chestnut.org/li/apss/csat/protocols or www.chestnut.org/li/bookstore – SAMHSA at http://kap.samhsa.gov/products/manuals/cyt/index.htm or NCADI at www.health.org Adolescent Treatment Programs and Studies – List of programs by state and summary of pre-2002 studies at www.drugstrategies.com – Cannabis Youth Treatment (CYT) : www.chestnut.org/li/cyt – Persistent Effects of Treatment Study of Adolescents (PETSA): www.samhsa.gov/centers/csat/csat.html (then select PETS from program resources) – Adolescent Program Support Site (APSS): www.chestnut.org/li/apss Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) – Website at www.chestnut.org/li/apss/sasate with bibliography – E-mail Darren Fulmore to be added to list server – Next conference is March 21-23, 2005, See website or E-mail Darren for information about meeting

92. References Babor, T. F., Webb, C. P. M., Burleson, J. A., & Kaminer, Y. (2002). Subtypes for classifying adolescents with marijuana use disorders Construct validity and clinical implications. Addiction, 97(Suppl. 1), S58-S69. Buchan, B. J., Dennis, M. L., Tims, F. M., & Diamond, G. S. (2002). Cannabis use Consistency and validity of self report, on- site urine testing, and laboratory testing. Addiction, 97(Suppl. 1), S98-S108. Bukstein, O.G., & Kithas, J. (2002) Pharmacologic treatment of substance abuse disorders. In Rosenberg, D., Davanzo, P., Gershon, S. (Eds.), Pharmacotherapy for Child and Adolescent Psychiatric Disorders, Second Edition, Revised and Expanded. NY, NY: Marcel Dekker, Inc. Dennis, M.L., (2002). Treatment Research on Adolescents Drug and Alcohol Abuse: Despite Progress, Many Challenges Remain. Connections, May, 1-2,7, and Data from the OAS 1999 National Household Survey on Drug Abuse Dennis, M.L. (2004). Traumatic victimization among adolescents in substance abuse treatment: Time to stop ignoring the elephant in our counseling rooms. Counselor, April, 36-40. Dennis, M.L., & Adams, L. (2001). Bloomington Junior High School (BJHS) 2000 Youth Survey: Main Findings. Bloomington, IL: Chestnut Health Systems Dennis, M. L., Babor, T., Roebuck, M. C., & Donaldson, J. (2002). Changing the focus The case for recognizing and treating marijuana use disorders. Addiction, 97 (Suppl. 1), S4-S15. Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003). The need for developing and evaluating adolescent treatment models. In S.J. Stevens & A.R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary Models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press and 1998 NHSDA. 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., & Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment, 27, 197-213. Dennis, M. L., Godley, S. and Titus, J. (1999). Co-occurring psychiatric problems among adolescents: Variations by treatment, level of care and gender. TIE Communiqué (pp. 5-8 and 16). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Dennis, M. L., Perl, H. I., Huebner, R. B., & McLellan, A. T. (2000). Twenty-five strategies for improving the design, implementation and analysis of health services research related to alcohol and other drug abuse treatment. Addiction, 95, S281- S308. Dennis, M. L. and McGeary, K. A. (1999). Adolescent alcohol and marijuana treatment: Kids need it now. TIE Communiqué (pp. 10-12). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

93. References - continued Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F., Webb, C., Kaminer, Y., Babor, T., Roebeck, M. C., Godley, M. D., Hamilton, N., Liddle, H., Scott, C., & CYT Steering Committee. (2002). The Cannabis Youth Treatment (CYT) experiment Rationale, study design, and analysis plans. Addiction, 97, 16-34.. Dennis, M. L., Titus, J. C., White, M., Unsicker, J., & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN) Administration guide for the GAIN and related measures. (Version 5 ed.). Bloomington, IL Chestnut Health Systems. Retrieve from http//www.chestnut.org/li/gain 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 http://www.drugstrategies.org 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. 2004 Feb. Diamond, G., Leckrone, J., & Dennis, M. L. (In press). The Cannabis Youth Treatment study Clinical and empirical developments. In R. Roffman, & R. Stephens, (Eds.) Cannabis dependence Its nature, consequences, and treatment. Cambridge, UK Cambridge University Press. Diamond, G., Panichelli-Mindel, S. M., Shera, D., Dennis, M. L., Tims, F., & Ungemack, J. (in press). Psychiatric syndromes in adolescents seeking outpatient treatment for marijuana with abuse and dependency in outpatient treatment. Journal of Child and Adolescent Substance Abuse. French, M.T., Roebuck, M.C., Dennis, M.L., Diamond, G., Godley, S.H., Tims, F., Webb, C., & Herrell, J.M. (2002). The economic cost of outpatient marijuana treatment for adolescents: Findings from a multisite experiment. Addiction, 97, S84-S97. French, M. T., Roebuck, M. C., Dennis, M. L., Diamond, G., Godley, S. H., Liddle, H. A., and Tims, F. M. (2003). Outpatient marijuana treatment for adolescents Economic evaluation of a multisite field experiment. Evaluation Review,27(4)421-459. Funk, R. R., McDermeit, 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, 36-45. 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 (s2), 129-139, Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. (2002). Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment, 23, 21-32. Godley, S. H., Jones, N., Funk, R., Ives, M., and Passetti, L. L. (2004). Comparing Outcomes of Best-Practice and Research- Based Outpatient Treatment Protocols for Adolescents. Journal of Psychoactive Drugs, 36, 35-48. Godley, M. D., Kahn, J. H., Dennis, M. L., Godley, S. H., & Funk, R. R. (in press). The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment. Psychology of Addictive Behaviors.

94. References - continued Hser, Y., Grella, C. E., Hubbard, R. L., Hsieh, S. C., Fletcher, B. W., Brown, B. S., & Anglin, M. D. (2001). An evaluation of drug treatments for adolescents in four U.S. cities. Archives of General Psychiatry, 58, 689-695. Lewinsohn, P.M., Hops, H., Roberts, R.E., Seeley, J.R., Andrews, J.A. (1993). Adolescent psychopathology, I: prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abn Psychol, 102, 133-144. National Academy of Sciences (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research. Washington, DC: National Academy Press. Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics. Office of Applied Studies (OAS) (1999). Treatment Episode Data Set (TEDS) 1992-1997: National admissions to substance abuse treatment services. Rockville, MD: Author. [Available online at.] Office of Applied Studies (OAS) (2000). Treatment Episode Data Set (TEDS) 1993-1998: National admissions to substance abuse treatment services. Rockville, MD: Author. [Available on line at.] Office of Applied Studies. (2000). National Household Survey on Drug Abuse: Main Findings 1998. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved, from http://www.samhsa.gov/statistics Office of Applied Studies 1992- 2002 Treatment Episode Data Set (TEDS) retrived from http://www.samhsa.gov/oas/dasis.htm Physician Leadership on National Drug Policy (PNLDP, 2002) Adolescent Substance Abuse: A Public Health Priority. Providence, RI: Brown University. Retrieved from http://www.plndp.org/Physician_Leadership/Resources/resources.html Shane, P., Jasiukaitis, P., & Green, R. S. (2003). Treatment outcomes among adolescents with substance abuse problems: The relationship between comorbidities and post-treatment substance involvement. Evaluation and Program Planning, 26, 393-402. Tims, F. M., Dennis, M. L., Hamilton, N., Buchan, B. J., Diamond, G. S., Funk, R., & Brantley, L. B. (2002). Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment. Addiction, 97, 46-57. Titus, J. C., Dennis, M. L., White, W. L., Scott, C. K., & Funk, R. R. (2003). Gender differences in victimization severity and outcomes among adolescents treated for substance abuse. Journal of Child Maltreatment, 8, 19-35. 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), 67-69. White, M. K., White, W. L., & Dennis, M. L. (2004). Emerging models of effective adolescent substance abuse treatment. Counselor, 5(2), 24-28. D. Wright (2004). State Estimates of Substance Use from the 2002 National Survey on Drug Use and Health. Rockville, MD: OAS, SAMHSA. http://oas.samhsa.gov/2k2State/PDFW/2k2SAEW.pdf