Intervening with Adolescent Substance User: What do we know so far about and where do we go from here Michael Dennis, Ph.D. Chestnut Health Systems, Normal,

Intervening with Adolescent Substance User:What do we know so far about and where do we go from here

Michael Dennis, Ph.D.Chestnut Health Systems, Normal, IL

October 29, 2009

Presentation for Washington State and Regional Policy Makers at the Puget Sound Educational School District, Renton, WA, October 27-30, 2009. This presentation was supported by PSESD, ESD113, and King County. The author would like to thank Dennis Deck for providing the tables of 2009 SAPISP data. The presentation also 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 Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761, phone 309-451-7801, fax 309-451-7765, e-Mail: [email protected] Questions about the GAIN can also be sent to [email protected]

mailto:[email protected]

mailto:[email protected]

Crime & Violence by Substance Severity

0%

10%

20%

30%

40%

50%

60%

Serious FightAt School

Fighting withGroup

Sold Drugs Attacked withintent to harm

Stole (>$50) CarriedHandgun

Dependence (3.9%) Abuse (4.2%)

Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)

Light Alc Use (12.4%) No PY AOD Use (64.3%)

Source: NSDUH 2006

Adolescents 12-17Substance use severity is related to crime and violence

Family, Vocational & MH by Substance Severity

Source: NSDUH 2006

0%

10%

20%

30%

40%

50%

60%

10 or MoreArguments with

Parents

Disliked School GPA = D orlower

MajorDepression

Any MHTreatment

Dependence (3.9%) Abuse (4.2%)

Weekly AOD Use (6.4%) Any Drug or Heavy Alc Use (8.8%)

Light Alc Use (12.4%) No PY AOD Use (64.3%)

Adolescents 12-17..as well as family, school

and mental health problems

People Entering Publicly Funded Treatment Generally Use For Decades

Per

cen

t st

ill u

sin

g

Years from first use to 1+ years of abstinence302520151050

Source: Dennis et al., 2005

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

It takes 27 years before half reach 1 or more years of abstinence or die

Per

cen

t st

ill u

sin

g

Years from first use to 1+ years of abstinence

under 15

21+

15-20

Age of First Use*

302520151050


100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

60% longer

The Younger They Start, The Longer They Use

* p<.05

Per

cen

t st

ill u

sin

g

Years from first use to 1+ years of abstinence

Years to first Treatment Admission*

302520151050


100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

20 or more years

0 to 9 years

10 to 19 years

57% quicker

The Sooner They Get The Treatment, The Quicker They Get To Abstinence

•p<.05

After Initial Treatment…

Relapse is common, particularly for those who: – Are Younger– Have already been to treatment multiple times – Have more mental health issues or pain

It takes an average of 3 to 4 treatment admissions over 9 years before half reach a year of abstinence

Yet over 2/3rds do eventually abstain

Treatment predicts who starts abstinence

Self help engagement predicts who stays abstinent

Source: Dennis et al., 2005, Scott et al 2005

The Likelihood of Sustaining Abstinence Another Year Grows Over Time

36%

66%

86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 to 12 months 1 to 3 years 4 to 7 years

Duration of Abstinence

% S

usta

inin

g A

bsti

nenc

eA

noth

er Y

ear

.

After 1 to 3 years of abstinence, 2/3rds will make it another year

After 4 years of abstinence,

about 86% will make it

another year

Source: Dennis, Foss & Scott (2007)

Only a third of people with

1 to 12 months of abstinence will

sustain it another year

But even after 7 years of abstinence, about

14% relapse each year

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.

In the Community

Using (75% stable)

In Treatment

(48 v 35% stable)

In Recovery (62% stable)

Source: 2006 CSAT AT data set

26% 19%

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

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-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Per

cent

in P

ast

Mon

th R

ecov

ery* Outpatient (+79%, -1%)

Residential(+143%, +17%)

Post Corr/Res (+220%, +18%)

OP & Resid

Similar

CC better

Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004

Cost of Substance Abuse Treatment Episode

$407

$1,249$1,132$1,384$2,486$2,907$4,277

$14,818

$0

$1

0,0

00

$2

0,0

00

$3

0,0

00

$4

0,0

00

$5

0,0

00

$6

0,0

00

$7

0,0

00

Screening & Brief Inter.(1-2 days)In-prison Therap. Com. (28 weeks)

Outpatient (18 weeks)Intensive Outpatient (12 weeks)

Treatment Drug Court (46 weeks)

Residential (13 weeks)Methadone Maintenance (87 weeks)Therapeutic Community (33 weeks)

$22,000 / year to incarcerate

an adult

$30,000/ child-year in foster care

$70,000/year to keep a child in

detention

• $750 per night in Detox• $1,115 per night in hospital • $13,000 per week in intensive care for premature baby• $27,000 per robbery• $67,000 per assault

Investing in Treatment has a Positive Annual Return on Investment (ROI)

Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested

Even year long treatment drug courts have an average ROI of $2.14 to $2.71 per dollar invested

Source: Bhati et al., (2008); Ettner et al., (2006)

This also means that for every dollar treatment is cut, we lose more money than we saved.

Washington Youth Served by Treatment & SAP are already costing society

Using the GAIN we are able estimate the cost to society of tangible services (e.g., health care utilization, days in detention, probation, parole, days of missed school) in 2009 dollars for the 90 days before intake

The 258 adolescents served by ESD113 in the 2008-9 school year…

– cost society $229,830 ($919.322 per year)– an average of $891 per adolescent ($3,663 per year)

The 2,733 adolescents served in King County between 2005-2009…

– cost society $4,609,580 ($18.438,321 per year)– an average of $1,687 per adolescent ($6,747 per year)

Thus both are targeting groups with a high potential to offset their costs to society (or cost you more if you cut back on them)

8.9%

21.2%

7.3%

0.6%1.0%0.5%0%

5%

10%

15%

20%

25%

12 to 17 18 to 25 26 or older

Abuse or Dependence in past yearTreatment in past year

Substance Use Disorders are Common,But Treatment Participation Rates Are Low:United States (US)

Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

Over 88% of adolescent and young adult treatment and

over 50% of adult treatment is publicly funded

Few Get Treatment: 1 in 17 adolescents,

1 in 22 young adults, 1 in 12 adults

Much of the private funding is limited to 30

days or less and authorized day by day

or week by week

9.0%

23.1%

8.0%

0.6%3.40%

0.50%0%

5%

10%

15%

20%

25%

12 to 17 18 to 25 26 or older


Substance Use Disorders are Common,But Treatment Participation Rates Are Low:Washington State


Similar rates for adolescents :

1 in 18

Higher problem rate for young adults, but higher

treatment rate : 1 in 7

Higher problems rate, and less

treatment participation for

adults:1 in 19

8.4%

23.3%

8.2%

0.6%1.2%0.2%0%

5%

10%

15%

20%

25%

12 to 17 18 to 25 26 or older


Substance Use Disorders are Common,But Treatment Participation Rates Are Low:Seattle & King County, WA


High higher problems rate, but similar treatment rates: 1 in 19 young adults

1 in 12 adults

Similar problem rate but much

lower Treatment Rate: 1 in 40 adolescents

Adolescent Rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting

in Washington State

77% 86

%

73%

75%

61%67

%

83%

62%

75%

60%

57%

40% 46

%

12%

12%

47%

37%

35%

12%

11%

0%10%20%30%40%50%60%70%80%90%

100%

Substance AbuseTreatment(n=8,213)

Student AssistancePrograms(n=8,777)

Juvenile Justice(n=2,024)

Mental HealthTreatment (10,937)

Children'sAdministration

(n=239)

Either High on Mental Health High on Substance High on Both

Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

Problems could be easily identified Comorbidity is common

http://publications.rda.dshs.wa.gov/1392/

0 5000 10000 15000 20000 25000

Mental Health(21,568)

Substance AbuseNeed (10,464)

Co-occurring(9,155)

Substance Abuse Treatment Student Assistance ProgramJuvenile Justice Mental Health TreatmentChildren's Administration

Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-ocurring?



26%

45%

42%

34%

34%

35%

6%

9%

8%

34%

13%

14%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mental Health(21,568)

Substance AbuseNeed (10,464)

Co-occurring(9,155)

Substance Abuse Treatment Student Assistance ProgramJuvenile Justice Mental Health TreatmentChildren's Administration

Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-ocurring?


<1%

<1%

<1%


35%

12%

11%

56%

34%

15%

9%

47%

0%10%20%30%40%50%60%70%80%90%

100%

Substance AbuseTreatment (n=8,213)

Juvenile Justice(n=2,024)

Mental HealthTreatment (10,937)

Children'sAdministration

(n=239)

GAIN Short Screener Clinical Indicators


Adolescent Client Validation of Hi Co-occurring from GAIN Short Screener vs Clinical Records

by Setting in Washington State

Two page measure closely approximated all found in the clinical record after the next two years


GAIN SS Can Also be Used for Monitoring

109

11

910

8

32 2

0

4

8

12

16

20

Intake 3Mon

6Mon

9Mon

12Mon

15Mon

18Mon

21Mon

24Mon

Total Disorder Screener (TDScr)

12+ Mon.s ago (#1s)

2-12 Mon.s ago (#2s)

Past Month (#3s)

Lifetime (#1,2,or 3)

Track Gap Between Prior and current

Lifetime Problems to identify “under

reporting”

Track progress in reducing current

(past month) symptoms)

Monitor for Relapse

23

SAPISP Results: State Wide (n=10,924)

8% 9% 6% 1%

19% 13%9%

4%

8%

18% 28%

11%

8%

6%

20%23%

17%

6%

17%15%

13% 30%

4%18% 12%

44% 40%

5%

72%16%

0%10%

20%30%

40%50%60%

70%80%

90%100%

Inte

rnal

izin

gD

isor

der

Ext

erna

lizi

ngD

isor

der

Subs

tanc

eD

isor

der

Cri

me/

Vio

lenc

e (C

V)

No

of P

rob.

0

1

2

3

4

5+

Source: SAPISP 2009 Data

WA Statedichotomizes as

0-1=Low2+=High

GAIN SS uses triage:

0=Low1-2=Mod3+=High

0%1%2%3%4%5%6%7%8%9%

10%11%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Total Disorder Sceener (TDScr) Score

% w

ithi

n L

evel

of

Car

e

Residential (n=1,965)

OP/IOP (n=2,499)

SAP (n=10,649)

Low

Mod. High ->

24

Total Disorder Screener Severity by Level of Care

Source: SAPISP 2009 Data and Dennis et al 2006

Residential Median (10.5) is higher

Outpatient & Student Asst. Prog. are Similar

(Median 6.0 vs. 6.4)

Well Targeted 95% 1+85% 3+ About 30% of OP & SAP are in the high

severity range more typical of residential

Internalizing Disorder Screener by Level of Care

Source: SAPISP 2009 Data and CSAT 2008 Full subset to Adolescent Intakes

45%

48%

43%

35%

37%

23%

28%

22%

37%

35%

33%

36%

36%

36%

33%

34%

18%

23%

29%

27%

41%

39%

45%

18%

0% 20% 40% 60% 80% 100%

High Moderate Low SAP Higher on Internalizing Disorders

Externalizing Disorder Screener by Level of Care

51%

67%

62%

51%

59%

44%

42%

37%

37%

22%

21%

23%

19%

26%

27%

27%

12%

12%

17%

25%

22%

29%

32%

36%

0% 20% 40% 60% 80% 100%

High Moderate Low


SAP Mod-Hi on Externalizing Disorders

Substance Disorder Screener by Level of Care

26%

82%

71%

70%

73%

52%

50%

39%

29%

17%

20%

26%

14%

31%

33%

40%

44%

1%

9%

4%

17%

20%

17%

14%

0% 20% 40% 60% 80% 100%

High Moderate Low


SAP Lower on Substance Disorders

Crime/Violence Screener by Level of Care

13%

55%

53%

40%

45%

41%

33%

24%

47%

31%

29%

36%

31%

37%

35%

38%

40%

14%

17%

24%

24%

22%

33%

38%

0% 20% 40% 60% 80% 100%

High Moderate Low


SAP Lower on Crime/Violence

29

King County: Pattern of Weekly Use

58%

17%

39%

3%

3%

7%

2%

47%

18%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Anything

Alcohol

Cannabis

Cocaine

Opioid

Other Drugs

Needle Use

Tobacco

Controlled Environment

Source: King County 08/31/09 (n=3102)

30

King County: Substance Use Disorder Severity

79%

60%

48%

24%

3%

89%

29%

29%

63%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Past Year Substance Diagnosis

3 or More Years of Use

Any Past Year Dependence

Any withdrawal symptoms in the past week

Severe withdrawal (11+ symptoms) in past week

Can Give 1+ Reasons to Quit*

Client believes Need ANY Treatment

Acknowledges having an AOD problem

Any prior substance abuse treatment


31

King County: Co-Occurring Psychiatric Problems

59%

43%

38%

28%

21%

10%

63%

43%

37%

17%

11%

37%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any Co-occurring Psychiatric

Conduct Disorder

Attention Deficit/Hyperactivity Disorder

Major Depressive Disorder

Traumatic Stress Disorder

General Anxiety Disorder

Ever Physical, Sexual or Emotional Victimization

High severity victimization (GVS>3)

Ever Homeless or Runaway

Any homicidal/suicidal thoughts past year

Any Self Mutilation*

Prior Mental Health Treatment


Externalizing Disorders

Internalizing Disorders

32

King County: Recovery Environment

49%

42%

28%

70%

59%

10%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Social Peers Getting Drunk Weekly+

School/Work Peers Getting DrunkWeekly+

Others at Home Getting DrunkWeekly+

Social Peers Using Drugs

School/Work Peers Using Drugs

Others at Home Using Drugs


33

King County: Past Year Violence & Crime

*Dealing, manufacturing, prostitution, gambling (does not include simple possession or use)

62%

53%

39%

31%

24%

21%

60%

47%

37%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any violence or illegal activity

Physical Violence

Any Illegal Activity

Any Property Crimes

Any Interpersonal/ Violent Crime

Other Drug Related Crimes*

Prior Juvenile Justice Involvement

Current Juvenile Justice involvement

1+/90 days In Controlled Environment


Past arrest/JJ/CJ status

8%

Other JJ/CJ status18%

In detention/jail 14-29 days

6%

In detention/jail 30+ days

1%

Past year illegal activity/SA use

45%

On prob/parole 14+ days w/ 1+

drug screens11%

Other prob/parole/ detention

11%

34

King County: Intensity of Juvenile Justice System Involvement


35

King County: Count Number of Problems Mod/Hi*

55%

13%

11%

11%

10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total (n=3102)

No SR prob

1 Prob.

2 Probs.

3 Probs.

4+ Probs.

* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)Source: King County 08/31/09 (n=3102)

Over 90% self report

one or more major

clinical problems

Over half report 5 or more major

clinical problems

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

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

Impact of the numbers of Favorable features on Recidivism (509 JJ studies)

Source: Adapted from Lipsey, 1997, 2005

Average Practice

Recidivism Drops the

more factors present

553/771=72%unmet need

218/224=97% to targeted

771/982=79% in need

Exploring Need, Unmet Need, & Targeting of Mental Health Services in AAFT

Size of the Problem

Extent to which services are currently being targeted

Extent to which services are not reaching those in most need

At Intake .

After 3 mon

No/Low

Need

Mod/High

Need

Total

Any Treatment 6 218 224

No Treatment 205 553 758

Total 211 771 982

Mental Health Problem (at intake) vs. Any MH Treatment by 3 months

79%

97%

72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of Clients WithMod/High Need

(n=771/982)*

% w Need but No ServiceAfter 3 months

(n=553/771)

% of Services Going toThose in Need

(n=218/224)

*3+ on ASAM dimension B3 criteriaSource: 2008 CSAT AAFT Summary Analytic Dataset

Why Do We Care About Unmet Need?

If we subset to those in need, getting mental health services predicts reduced mental health problems

Both psychosocial and medication interventions are associated with reduced problems

If we subset to those NOT in need, getting mental health services does NOT predict change in mental health problems

Conversely, we also care about services being poorly targeted to those in need.

Residential Treatment need (at intake) vs. 7+ Residential days at 3 months

36%

52%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of Clients WithMod/High Need

(n=349/980)*

% w Need but NoService After 3 months

(n=315/349)

% of Services Going toThose in Need (n=34/66)

Opportunity to redirect

existing funds through better

targeting

Source: 2008 CSAT AAFT Summary Analytic Dataset

Documents

Intervening with Adolescent Substance User: What do we know so far about and where do we go from here Michael Dennis, Ph.D. Chestnut Health Systems, Normal,