American Evaluation Association 2006 Conference Portland, OR, November 4, 2006

1. How Symptom Severity Varies Depending on Age & the Substance of Abuse Michael Dennis & Ya-Fen Chan, Chestnut Health SystemsKendon Conrad, University of Illinois at Chicago American Evaluation Association 2006 Conference Portland, OR, November 4, 2006 Multi-paper Session 289 (Applications of the Rasch Measurement Model in Evaluation ) to be held in Salon Ballroom I on Thursday, November 2, 1:40 PM to 3:10 PM

2. Acknowledgement This presentation was supported by analytic runs provided Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT) under Contracts 207-98-7047, 277-00-6500, and 270-2003-00006 using data provided by the following grantees: CSAT (T100664, 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, TI11320, TI12541, TI00567); NIAAA (R01 AA 10368); NIDA (R37 DA11323; R01 DA 018183; 1R01 DA15523); Illinois Criminal Justice Information Authority (95-DB-VX-0017); Illinois Office of Alcoholism and Substance Abuse (PI 00567); Intervention Foundation’s Drug Outcome Monitoring Study (DOMS), Robert Woods Johnson Foundation’s Reclaiming Futures. Any opinions about this data are those of the authors and do not reflect official positions of the government or individual grantees. 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. Unresolved Questions from DSM’s Substance Use Disorder Criteria • Do abuse and dependence symptoms vary along the same or different dimensions? • Should the systems be weighted equally or • Are physiological symptoms (tolerance and withdrawal) good markers of high severity? • Are abuse symptoms good markers of low severity? • Does the average and pattern of symptom severity vary by age & substance? Are all relevant? • Are diagnostic orphans (1-2 symptoms of dependence without abuse) similar to abuse or lower? • Are multi-morbidity or age of on-set a good prognostic marker of severity? For a more detailed list of issues, see Schuckit, MA & Saunders, JB (2006). The empirical basis of substance use disorders diagnosis: research recommendations for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V). Addiction, 101 (suppl 1.), 170-173.

4. Data Source and Methods • Data from 2474 Adolescents, 344 Young Adults and 661 Adults interviewed between 1998 and 2005 with the Global Appraisal of Individual Needs (GAIN; Dennis et al 2003) • Participants recruited at intake to Early Intervention, Outpatient, Intensive Outpatient, Short, Moderate & Long term Residential, Corrections Based and Post Residential Outpatient Continuing Care as part of 72 local evaluations around the U.S. and pooled into a common data set • Analysis here focuses on the GAIN Substance Use Disorder Scale (SUDS) with symptoms of dependence and abuse overall and by substance. The rating scale is 3=past month, 2=past 2-12 months, 1=more than a year ago and 0=never. • Analyses done with a combination of Winsteps and Facets

5. Withdrawal (+0.34) Despite Legal (+0.10) Desp.PH/MH (+0.10) Give up act. (+0.05) Can't stop (+0.05) Tolerance (0.00) Hazardous (-0.03) Loss of Contro (-0.10) Fights/troub. (0.17) Role Failure (-0.12) Time Cons. (-0.21) Physiological Sx: While Withdrawal is High severity, Tolerance is only Moderate Dependence Sx: Other dependence Symptoms spread over continuum Abuse Sx: Abuse Symptoms are also spread over continuum Common Dimension of Dependence & Abuse Symptom Severity Loss of Control Desp.PH/MH Despite Legal Fights/troub. Role Failure Give up act. Time Cons Withdrawal Hazardous Tolerance Can't stop 0.80 1st dimension explains 75% of variance (2nd explains 1.2%) Average Item Severity (0.00) 0.60 0.40 0.20 Rasch Severity Measure 0.00 -0.20 -0.40 -0.60

6. Continued use in spite of legal problems more likely among Adol/YA Adults more likely to endorse most symptoms Symptom Severity Vary By Age Loss of Control Desp.PH/MH Despite Legal Fights/troub. Role Failure Give up act. Time Cons. Withdrawal Hazardous Tolerance Can't stop 1.8 26+ 1.6 Age 1.4 <18 18-25 1.2 26+ 1 18- 0.8 18- <18 25 25 0.6 Rasch Severity Measure 26+ 18- 18- <18 0.4 25 26+ 26+ 25 <18 <18 <18 <18 18- 0.2 18- 26+ 18- <18 25 25 25 18- 18- 0 26+ 25 <18 25 <18 26+ <18 18- 26+ -0.2 25 18- -0.4 18- 26+ 25 26+ 25 26+ -0.6 <18 <18 -0.8 26+ -1 Hazardous use more likely among Adol/YA More likely to lead to fights among Adol/YA

7. 1. Average goes up with age 2. Complete overlap in range 3. Narrowing of distribution on higher severity at older ages Average Severity by Age 2.00 1.50 1.00 0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00 Adolescent (<18) Young Adult (18-25) Adult (26+)

8. Withdrawal much less likely for CAN Easier to endorse despite legal problem for ALC/CAN Easier to endorse moderate Sx for COC/OPI Easier to endorse hazardous use for ALC/CAN Easier to endorse Withdrawal for AMP/OPI Easier to endorse fighting/ trouble for ALC/CAN Easier to endorse time consuming for CAN Symptom Severity Vary by Substance Loss of Control Desp.PH/MH Despite Legal Fights/troub. Role Failure Give up act. Time Cons. Withdrawal Hazardous Tolerance Can't stop 0.80 AVG (0.00) CAN AMP (+0.89) 0.60 OPI (+0.44) COC (-0.22) ALC (-0.44) 0.40 CAN (-0.67) COC ALC COC OPI Rasch Severity Measure CAN 0.20 ALC ALC CAN ALC AMP AMP ALC AMP AMP COC CAN COC CAN AMP ALC OPI OPI OPI OPI CAN 0.00 AMP CAN AMP OPI COC OPI COC OPI OPI CAN OPI AMP COC AMP ALC ALC COC ALC AMP CAN COC OPI COC COC AMP -0.20 ALC ALC CAN -0.40 CAN -0.60

9. Diagnostic Orphans (1-2 dependence symptoms) are lower, but still overlap with other clinical groups Rasch Severity by Past Month Status 2.00 1.50 1.00 0.50 0.00 -0.50 Rasch Severity Measure -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 Dependence Only Both Abuse and Dependence None Diagnostic Orphan in early remission Diagnostic Orphan Lifetime SUD in CE 45+ days Abuse Only Lifetime SUD in early remission

10. 2.00 1.50 1.00 0.50 0.00 -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00 0 1 2 3 4 5 6 7 8 9 10 11 Severity by Past Year Symptom Count 1. Better Gradation 2. Still a lot of overlap in range Rasch Severity Measure

11. Severity by Number of Past Year SUD Diagnoses 1. Better Gradation 2. Less overlap in range 2.00 1.50 1.00 0.50 0.00 Rasch Severity Measure -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00 0 1 2 3 4 5

12. Severity by Weighted (past month=2, past year=1) Number of Substance x SUD Symptoms 1. Better Gradation 2. Much less overlap in range 2.00 1.50 1.00 0.50 0.00 Rasch Severity Measure -0.50 -1.00 -1.50 -2.00 -2.50 -3.00 -3.50 -4.00 0 1-4 5-8 9-12 13-16 17-20 21-24 25-30 31-40 41+

13. Pathways to Recovery Study (Scott & Dennis) Recruitment: 1995 to 1997 Sample: 1,326 participants from sequential admissions to a stratified sample of 22 treatment units in 12 facilities, administered by 10 agencies on Chicago's west side. Levels of Care: Adult OP, IOP, MTP, HH, STR, LTR Instrument: Augmented version of the Addiction Severity Index (A-ASI) Follow-up: Of those alive and due, follow-up interviews were completed with 94 to 98% in annual interviews out to 8 years (going to 10 years); over 80% completed within +/- 1 week of target date. Source: Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment careers. Journal of Substance Abuse Treatment, 28, S51-S62.

14. Substance Use Careers Last for Decades 100% 90% 80% Percent in Recovery 70% Median duration of 27 years (IQR: 18 to 30+) Years from first use to 1+ years abstinence 60% 50% 40% 30% 20% 10% 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

15. Substance Use Careers are Longer, the Younger the Age of First Use 100% 90% 21+ 80% Percent in Recovery 15-20* Age of 1st Use Groups 70% Years from first use to 1+ years abstinence 60% under 15* 50% 40% 30% 20% * p<.05 (different from 21+) 10% 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

16. Substance Use Careers are Shorter the Sooner People get to Treatment 100% 0-9* 90% 80% 10-19* Years to 1st Tx Groups Percent in Recovery 70% Years from first use to 1+ years abstinence 60% 50% 40% 20+ 30% 20% 10% * p<.05 (different from 20+) 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

17. Implications for SUD Concept • “Tolerance” is not a good marker of high severity; withdrawal (and substance induced health problems are) • “Abuse” symptoms are consistent with the overall syndrome and represent moderate severity or “other reasons to treat in the absence of the full blown syndrome” • Diagnostic orphans are lower severity, but relevant • Pattern of symptoms varies by substance and age, but all symptoms are relevant • “Adolescents” experienced the same range of symptoms, though they (and young adults) were particularly more likely to be involved with the law, use in hazardous situations, and to get into fights at lower severity • Symptom and/or diagnostic counts appear to be more useful than the current DSM approach to categorizing severity • Age of onset appears to be a good prognostic marker of severity