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 270-2003-00006 and 270-07-0191, 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 www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 448 Wylie Drive, Normal, IL 61761, phone: (309) 451-7801, Fax: (309) 451-7763, e-mail: junsicker@Chestnut.Org Chestnut Health Systems

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

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

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

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

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

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):371-377. Chestnut Health Systems

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 11:184-190, 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 14:169-177, 1993. Chestnut Health Systems

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

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

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

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

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

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

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

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 2002 to 136,660 in 2006 69% increase from 95,017 in 1992 to 160,750 in 2002 Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm Chestnut Health Systems

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): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

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): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .

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

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

22% decrease in the past decade Change in PA Public Treatment Admissions: Level of Care from 1992 to 2006 Dramatic Growth in 1992-1997 22% decrease in the past decade Decreased use of Detox Source: OAS, 2006 – 1992-2006 TEDS Data

Change in PA Public Treatment Admissions: Referral Source from 1995 to 2006 Close link to Juv. Just. Source: OAS, 2006 – 1992-2006 TEDS Data

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 – 1992-2006 TEDS Data

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 2,3,4,5 ---- 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

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 (+5998.00) - 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

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

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

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