1. State of the Art of Adolescent Substance Abuse Treatment Michael Dennis, Ph.D. Chestnut Health Systems, Normal, IL Presentation on February 18, 2009 for Pavillon Foster Addiction Treatment Centre and l’Association des centres de réadaptation en dépendance du Québec (ACRDQ), Montreal, Quebece, Canada. 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

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

3. 3 Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246) Dependence 5% Abuse 4% Regular AOD Use 8% Any Infrequent Drug Use 4% Light Alcohol Use Only 47% No Alcohol or Drug Use 32% Source: 2002 NSDUH; Dennis & Scott 2007

4. 4 Problems Vary by Age 0 10 20 30 40 50 60 70 80 90 100 12-1314-1516-1718-2021-2930-3435-4950-64 65+ No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence NSDUH Age Groups Severity Category Adolescent Onset Remission Increasing rate of non- users Source: 2002 NSDUH; Dennis & Scott 2007

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

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

7. 7 Higher Severity is Associated with Higher Annual Cost to Society Per Person $0 $231 $725 $406 $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence Median (50 th percentile) $948 $1,613 $1,078 $1,309 $1,528 $3,058 Mean (95% CI) This includes people who are in recovery, elderly, or do not use because of health problems Higher Costs Source: 2002 NSDUH; Dennis & Scott 2007

8. 8 Brain Activity on PET Scan After Using Cocaine Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377. Rapid rise in brain activity after taking cocaine Actually ends up lower than they started

9. 9 Normal Cocaine Abuser (10 days) Cocaine Abuser (100 days) Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 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. Brain Activity on PET Scan After Using Cocaine With repeated use, there is a cumulative effect of reduced brain activity which requires increasingly more stimulation (i.e., tolerance) Even after 100 days of abstinence activity is still low

10. 10 Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine Still not back to normal after 7 years

11. 11 Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front

12. 12 Substance Use Careers Last for Decades Cumulative Survival Years from first use to 1+ years abstinence 302520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 Median of 27 years from first use to 1+ years abstinence Source: Dennis et al., 2005

13. 13 Substance Use Careers are Longer the Younger the Age of First Use Cumulative Survival Years from first use to 1+ years abstinence under 15* 21+ 15-20* Age of 1 st Use Groups * p<.05 (different from 21+) 302520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 Source: Dennis et al., 2005

14. 14 Substance Use Careers are Shorter the Sooner People Get to Treatment Cumulative Survival 20+ 0-9* 10-19* Year to 1 st Tx Groups 302520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 * p<.05 (different from 20+) Source: Dennis et al., 2005 Years from first use to 1+ years abstinence

15. 15 Treatment Careers Last for Years Cumulative Survival Years from first Tx to 1+ years abstinence 2520151050 1.0.9.8.7.6.5.4.3.2.1 0.0 Median of 3 to 4 episodes of treatment over 9 years Source: Dennis et al., 2005

16. 16 15% 13% 8% 25% 20% 31% 7% 10% 15% 11% 12% 3% 7% 66% 77% 83% 58% 56% 39% 48% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Alcohol or Other Drug disorder Alcohol Disorder Drug DisorderExternalizing disorder Mood Disorder: Anxiety Disorder: Posttraumatic Stress Disorder Lifetime DiagnosisPast Year RemissionRemission Rate Lifetime Diagnosis and Remission Rates Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication SUD Remission Rates are BETTER than Other Major DSM Diagnoses

17. 17 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

18. 18 Comparison of US & CN Adolescents & Adults Source: Vega et al 2002 (using data from 1994-98) Cannabis the most common other drug

19. 19 Smoking Tobacco is Associated with More Frequent Alcohol & Cannabis Use Source: Davis 2004 Canadian Addiction Survey

20. 20 40 38 35 31 30 27 25 24 23 22 21 29 25 20 24 22 19 24 12 17 20 12 0 5 10 15 20 25 30 35 40 45 Canada Switzerland England United States Spain Scotland France Czech Republic Wales Slovenia Belgium The Netherlands Denmark 20022006 Change in Adolescent Past Year Cannabis Use Source: Kuntsche et al 2009, Health Behaviour in School-Aged Children (HBSC) study. Canada has had the highest rate of the 31 HBSC Study Countries All Went Down Canada had one of the largest drops

21. 21 Past Year Alcohol or Drug Abuse or Dependence Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH 8.9% National (but lots of geographic variation)

22. 22 GAP between Adolescent SUD & Treatment Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

23. 23 Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S. Source: Office of Applied Studies 1992- 2005 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm 69% increase from 95,017 in 1992 to 160,750 in 2002 15% drop off from 160,750 in 2002 to 136,660 in 2006

24. 24 Median Length of Stay is only 50 days Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 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. 0306090 Outpatient (37,048 discharges) IOP (10,292 discharges) Detox (3,185 discharges) STR (5,152 discharges) LTR (5,476 discharges) Total (61,153 discharges) Level of Care Median Length of Stay 50 days 49 days 46 days 59 days 21 days 3 days Less than 25% stay the 90 days or longer time recommended by NIDA Researchers

25. 25 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. Despite being widely recommended, only 10% step down after intensive treatment

26. 26 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

27. 27 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

28. 28 Major Predictors of Bigger Effects 1. Chose a strong intervention protocol based on prior evidence 2. Used quality assurance to ensure protocol adherence and project implementation 3. Used proactive case supervision of individual 4. Used triage to focus on the highest severity subgroup

29. 29 Impact of the numbers of Favorable features on Recidivism (509 JJ studies) Source: Adapted from Lipsey, 1997, 2005 Average Practice

30. 30 Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Recidivism (29% vs. 40%) Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving MET/CBT combinations and Other manualized CBT Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ACRA) Assertive Continuing Care Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004 NOTE: There is generally little or no differences in mean effect size between these brand names

31. 31 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

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

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

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

35. 35 GAIN Clinical Collaborators Adolescent and Adult Treatment Program 10/07 GAIN State System Virgin Islands 0 1 to 10 11 to 25 26 to 130 Indiana Kansas Maine Montana Nebraska Nevada North Dakota Puerto Rico Hawaii New Mexico South Dakota Alabama Arkansas Iowa Oklahoma Rhode Island South Carolina District Of Columbia Tennessee Utah Louisiana W. Virginia Minnesota Wisconsin New Jersey North Carolina Alaska Delaware Maryland Pennsylvania Georgia Kentucky Virginia Michigan New York Oregon Colorado Texas New Hampshire Connecticut Illinois Missouri Arizona Florida Ohio Vermont Idaho Massachusetts California Washington Wyoming GAIN-SS State or County System Number of GAIN Sites Mississippi

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

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

38. 38 Past Year Substance Severity by Level of Care Note: OP=Outpatient, IOP=Intensive Outpatient; LTR= Long Term Residential (90+ days); MTR= Moderate Term Residential (30-90 days); STR=Short Term Residential (0-30 days) Source: CSAT 2007 AT Outcome Data Set (n=12,824)

39. 39 Past 90 day HIV Risk Behaviors Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

40. 40 Sexual Partners by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

41. 41 Co-Occurring Psychiatric Problems Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

42. 42 Co-Occurring Psychiatric Diagnoses by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

43. 43 Severity of Victimization by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

44. 44 Severity of Victimization by Gender Source: CSAT 2007 AT Outcome Data Set (n=15,254)

45. 45 Past Year Violence & Crime *Dealing, manufacturing, prostitution, gambling (does not include simple possession or use) Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

46. 46 Type of Crime by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

47. 47 Multiple Problems* are the Norm Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254) Most acknowledge 1+ problems Few present with just one problem (the focus of traditional research) In fact, 45%present acknowledging 5+ major problems * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

48. 48 Number of Problems by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824)

49. 49 No. of Problems* by Severity of Victimization Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254) Those with high lifetime levels of victimization have 117 times higher odds of having 5+ major problems* * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Severity of Victimization

50. 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

51. 51 Context Circa 1997 Cannabis had become more potent, was associated with a wide of problems (particularly when combined with alcohol), and had become the leading substances mentioned in arrests, emergency room admissions, autopsies, and treatment admissions (doubling in in 5 years) Over 80% of adolescents with Cannabis problems were being seen in outpatient setting The median length of stay was 6 weeks, with only 25% making it 3 months There were no published manuals targeting adolescent marijuana users in outpatient treatment The purpose of CYT was to manualize five promising protocols, field test their relative effectiveness, cost, and benefit-cost and provide them to the field Source: Dennis et al, 2002

52. 52 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

53. 53 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

54. 54 $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 Integrating family therapy was less expensive than adding it

55. 55 CYT Increased Days Abstinent and Percent in Recovery* 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 *no use, abuse or dependence problems in the past month while in living in the community

56. 56 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 ** n.s.d., effect size f=0.12 * n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16 Not significantly different by condition. But better than the average for OP in ATM (200 days of abstinence)

57. 57 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

58. 58 36 Site Replication on MET/CBT5 AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY CYT: 4 Sites EAT: 36 Sites Source: Dennis, Ives, & Muck, 2008

59. 59 Range of Effect Sizes (d) for Change in Days of Abstinence (intake to 12 months) by Site 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 4 CYT Sites (f=0.39) (median within site d=0.29) 36 EAT Sites (f=0.21) (median within site d=0.49) 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 Cohen’s d Source: Dennis, Ives, & Muck, 2008 EAT Programs did Better than CYT on average 75% above CYT median 6 programs completely above CYT

60. 60 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

61. 61 The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents In the Community Using (75% stable) In Treatment (48% stable) In Recovery (62% stable) Incarcerated (46% stable) 5%5% 12% 7%7% 20% 24% 10% 26% 7 % 19% 7%7% 27% 3%3% Source: 2006 CSAT AT data set Avg of 39% change status each quarter P not the same in both directions Treatment is the most likely path to recovery More likely than adults to stay 90 days in treatment (OR=1.7) More likely than adults to be diverted to treatment (OR=4.0)

62. 62 In the Community Using (75% stable) 12% 27% Probability of Going from Use to Early “Recovery” (+ good) -Age (0.8) + Female (1.7), - Frequency Of Use (0.23) + Non-White (1.6) + Self efficacy to resist relapse (1.4) + Substance Abuse Treatment Index (1.96) * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity. In Recovery (62% stable) Probability of from Recovery to “Using” (+ good) - Freq. Of Use (0.0002) + Initial Weeks in Treatment (1.03) - Illegal Activity (0.70) + Treatment Received During Quarter (2.00) - Age (0.81) + Recovery Environment (r)* (1.45) + Positive Social Peers (r) (1.43) The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents

63. 63 In the Community Using (75% stable) In Treatment (48 v 35% stable) 7%7% Source: 2006 CSAT AT data set Probability of Going from Use to “Treatment” (+ good) -Age (0.7) + Times urine Tested (1.7), + Treatment Motivation (1.6) + Weeks in a Controlled Environment (1.4) The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents

64. 64 In the Community Using (75% stable) In Treatment (48 v 35% stable) In Recovery (62% stable) Source: 2006 CSAT AT data set 26% 19% The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents Probability of Going to Using vs. Early “Recovery” (+ good) -- Baseline Substance Use Severity (0.74) + Baseline Total Symptom Count (1.46) -- Past Month Substance Problems (0.48)+ Times Urine Screened (1.56) -- Substance Frequency (0.48)+ Recovery Environment (r)* (1.47) + Positive Social Peers (r)** (1.69) * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.

65. 65 In the Community Using (75% stable) In Recovery (62% stable) The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents * 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 20% 10% Incarcerated (46% stable) Probability of Going to Using vs. Early “Recovery” (+ good) + Recovery Environment (r)* (3.33) Source: 2006 CSAT AT data set

66. 66 Recovery* by Level of Care * Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT Adolescent Treatment Outcome Data Set (n-9,276) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pre-IntakeMon 1-3Mon 4-6Mon 7-9Mon 10-12 Percent in Past Month Recovery* Outpatient (+79%, -1%) Residential(+143%, +17%) Post Corr/Res (+220%, +18%) OP & Resid Similar CC better

67. 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) Over 90% follow-up 3, 6, & 9 months post discharge Source: Godley et al 2002, 2007

68. 68 Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17) Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0102030405060708090 Days after Residential (capped at 90) Percent of Clients Cont. Care Admis. Relapse

69. 69 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)

70. 70 Assertive Continuing Care (ACC) Hypotheses Assertive Continuin g Care General Continuin g Care Adherence Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA) Early Abstinence GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence Sustained Abstinence Early abstinence will be associated with higher rates of long term abstinence.

71. 71 ACC Improved Adherence Source: Godley et al 2002, 2007 0% 10% 20% 30% 40%50%60%70%80% WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/probation/school Follow up on referrals* ACC * p<.05 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 7/12 criteria* UCC

72. 72 GCCA Improved Early (0-3 mon.) Abstinence Source: Godley et al 2002, 2007 24% 36% 38% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=2.16*)Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA 43% 55% High (7-12/12) GCCA * p<.05

73. 73 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence Source: Godley et al 2002, 2007 19% 22% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=11.16*)Alcohol (OR=5.47*) Marijuana (OR=11.15*) Early(0-3 mon.) Relapse 69% 59% 73% Early (0-3 mon.) Abstainer * p<.05

74. 74 Post script on ACC The ACC intervention improved adolescent adherence to the continuing care expectations of both residential and outpatient staff; doing so improved the rates of short term abstinence and, consequently, long term abstinence. Despite these GAINs, many adolescents in ACC (and more in UCC) did not adhere to continuing care plans. The ACC1 main findings are published and findings from two subsequent experiments are currently under review CSAT is currently replicating ACRA/ACC in 32 sites The ACC manual is being distributed via the website and the CD you have been provided.

75. 75 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

76. 76 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

77. 77 The Growing Number of GAIN Sites in Canada AB BC MB NB NF NS NT ON PE QC SK YT Kirkland Ajax Bonavista Burgeo Burin Bay Arm Burlington Calgary Churchill Falls Clarenville Corner Brook Cornwall Creston Deer Lake Hamilton Kenora London Montreal Oshawa Pembroke Pt Hope Simpson Pt Saunders Richmond Sault Ste Marie Squamish St Anthony Stephenville Toronto Vancouver Whitbourne GAIN Instrument Used GAIN-I GAIN-SS