Implementing Evidenced Based Substance Abuse Services for Adolescents

1. Implementing Evidenced Based Substance Abuse Services for Adolescents Michael Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL Part of the continuing education workshop, � What Works? In Alcohol & Other (AOD) Treatment for Adolescents�, Marlborough, MA, April 21, 2005. Sponsored by Massachusetts Department of Public Health, Bureau of Substance Abuse Services & AdCare Educational Institute, Inc. The content of this presentations are based on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270-2003-00006 using data provided by the following grantees: (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888, TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340, TI130022, TI03345, TI012208, TI013323, TI14376, TI14261, TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272, TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678, TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674, TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514, TI15672, TI15478, TI15447, TI15545, TI15671)). several individual grants. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: junsicker@Chestnut.Org

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

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

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

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

7. So what does it mean to move the field towards Evidence Based Practice (EBP)? Introducing reliable and valid assessment that can be used At the individual level to immediately guide clinical judgments about diagnosis/severity, placement, treatment planning, and the response to treatment At the program level to drive program evaluation, needs assessment, and long term program planning Introducing explicit intervention protocols that are Targeted at specific problems/subgroups and outcomes Having explicit quality assurance procedures to cause adherence at the individual level and implementation at the program level Having the ability to evaluate performance and outcomes For the same program over time, Relative to other interventions

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

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

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

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

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

14. 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 15 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 14 individual research grants and CTN studies 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

15. Since 1997, the data has been pooled to create one of the largest benchmark data sets in the field

16. CSAT AT Program Common Data Set The working CSAT adolescent treatment data set including data on 5,468 adolescents from 67 local evaluations (current through quarterly data submission cycle ending in December 2004) All data collected with the Global Appraisal of Individual Needs (GAIN) using centrally trained and certified staff Outcome data through 12 months available on over 90% of CYT and ATM clients and over 80% of others �due� in on-going programs Programs include several standardized protocols based on both research and practice (ACC, ACRA, ATM, FFT, FSN, Matrix, MET/CBT, MDFT, MST) Local evaluations include several experiments and quasi experiments Several workgroups working on common themes across programs (African American, Co-morbidity, Family, Native American/Indian, Spanish translation/workforce) Data being shared with several secondary analysis grantees and panel presentations for this week First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

17. CSAT Adolescent Treatment (AT) Programs Reordered by Level of Care and Severity EAT: Effective Adolescent Treatment (2003-2007; n=975) replicating the CYT MET/CBT intervention in early intervention, school and outpatient settings(22 of 36 grants: Bradley, Brown, Clayton,Curry, Davis, Dillon, Dodge, Kressler, Kincaid, Levine, Levy, Locario, Mason, Moore, Rajaee-Moore, Paull, Payton, Rezende, Taylor, Tims, Turner, Vincent) CYT: Cannabis Youth Treatment (1997-2001; n=600) Experiments with adolescent outpatient/intensive outpatient (5 grants: Babor, Dennis, Diamond, Godley, Tims) TCE: Targeted Capacity Expansion (2002-2007; n=189) evaluation of intensive outpatient programs and some residential treatment (2 of 12 grants: Tims, Lloyd) SCY: Strengthening Communities-Youth (2002-2007; n=1120) evaluations of early intervention, outpatient, intensive outpatient and some residential (11 of 12 grants: Beach, Bolland, Dahl, Gerstel, Godley, Hall, Hutchinson, Keehn, Murphy, Noonan, Panzarella) ATM: Adolescent Treatment Model (1998-2002; n=1468) evaluations of outpatient, short and long term residential (10 grants: Batttjes, Fishman, Godley, Liddle, Morral, Perry, Sabin, Shane, Stevens-2) ART: Adolescent Residential Treatment (2003-2006; n=1179) evaluations of residential treatment enhancements and continuing care (17 grants: Beach, Fishman, Flores, Gay, Gnazzo, Hatch, Hurtig, Lane, Law, Manov, May, Miley, Nordquist, Snipes, Urquahart, Whitmore, Zammarelli) First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

18. Level of Care First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

19. Gender First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

20. Race First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

21. Age First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

22. Other Characteristics First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

23. Years of Use First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

24. Substance Use Severity (based on self-report) First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

25. Weekly/Daily Substance Use Pattern First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

26. Prior Substance Abuse Treatment First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

27. Mixed Problem Recognition First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

28. High Risk Recovery Environments First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

29. Patterns of Co-Occurring Disorders First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

30. Interventions need to be more specific First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

31. Also High Rates of HIV/STI risk behaviors First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

32. Severity of Victimization History First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

33. Victimization interacts with MH problems First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

34. Intensity of Juvenile Justice System Involvement First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

35. It is NOT just about possession� First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

36. Need to focus on multiple problems clients First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

37. Victimization is particularly intertwined with the number of problems*

38. Areas where staff wanted more specific knowledge and interventions Victimization, trauma and helplessness Self mutilation, para-suicidal and suicidal behaviors Anger management, violence and crime How to help their kids access mental health services (typically for internal disorders) when availability is limited Managing ADHD and impulsivity How to get parents involved in treatment and continuing care Tobacco, opioids, and methamphetamine use, Working with schools, probation, families Females, Males, African Americans, Native Americans, Spanish Speaking adolescents and their families HIV, STI, and Liver risk How to make interventions more assertive and strength based Evaluation issues like follow-up, data management, & analysis Workforce development, including peer-to-peer on specific treatment approaches and other job functions like MIS First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets] First, however, let me acknowledge that there were several problems with this early research and the ability of our field to translate it into practice. [read bullets]

39. Example: Recall Earlier finding about CHS OP

40. How do CHS OP�s high GVS outcomes compare with other OP programs on average?

41. Which 5 OP Programs Did the Best with High GVS adolescents?

42. Which 5 OP Programs Did the Best with High GVS adolescents?

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

44. Resources 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 Treatment Programs CSAT CYT, ATM, ACC and other treatment 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 National Registry of Effective Prevention ProgramsSubstance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services : http://www.modelprograms.samhsa.gov

45. Resources Implementing Evidenced based practice Central East ATTC Evidence Based Practice Resource Page http://www.ceattc.org/nidacsat_bpr.asp?id=LGBT Northwest Frontier ATTC Best Practices in Addiction Treatment: A Workshop Facilitator's Guide http://www.nattc.org/resPubs/bpat/index.html Turning Knowledge into Practice: A Manual for Behavioral Health Administrators and Practitioners About Understanding and Implementing Evidence-Based Practices http://www.tacinc.org/index/viewPage.cfm?pageId=114 Evidence-Based Practices: An Implementation Guide for Community-Based Substance Abuse Treatment Agencies http://www.uiowa.edu/~iowapic/files/EBP%20Guide%20-%20Revised%205-03.pdf National Center for Mental Health and Juvenile Justice Evidence Based Practice resource list at http://www.ncmhjj.com/EBP/default.asp 2005 Joint Meeting on Adolescent Substance Abuse Treatment Effectiveness http://www.mayatech.com/cti/csatsasatepost/ Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE) www.chestnut.org/li/apss/sasate

46. References Cited Here Beutler, L. E. (2000). David and Goliath When empirical and clinical standards of practice meet. American Psychologist, 55, 997-1007. Dennis, M. L., Scott, C. K., Funk, R. R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment. Journal of Substance Abuse Treatment, 28 (2S), S49-S60 . Dennis, M.L., & White, M.K. (2003). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through 2001, (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems. [On line] Available at 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. 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.