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

1. Understanding Adolescent Co-occurring Disorders and the Movement towards a more Effective Continuum of Community Care Michael Dennis, Ph.D. Chestnut Health Systems, Normal, IL Presentation on November 4, 2008 at a conference on “Continuum of Community Care (Models of Systems of Care) for Adolescents with Co-Occurring Disorders: Best Practices and Model Programs from around the Country“ sponsored by OdysseyNH and the Cassey Foundation. 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. 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 New Hampshire • 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

3. 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% Light Alcohol Use Only 47% Source: 2002 NSDUH

4. Adolescent Onset Remission Problems Vary by Age NSDUH Age Groups Increasing rate of non-users 100 Severity Category 90 No Alcohol or Drug Use 80 70 Light Alcohol Use Only 60 Any Infrequent Drug Use 50 40 Regular AOD Use 30 Abuse 20 10 Dependence 0 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

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

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

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

8. Brain Activity on PET Scan After Using Cocaine Rapid rise in brain activity after taking cocaine 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.

9. 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) 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.

10. Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

11. 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.

12. 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 .2 .1 0.0 0 5 10 15 20 25 30 Source: Dennis et al., 2005

13. Substance Use Careers are Longer the Younger the Age of First Use Age of 1st Use Groups 1.0 .9 .8 Cumulative Survival .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+) 0 5 10 15 20 25 30 Source: Dennis et al., 2005

14. Substance Use Careers are Shorter the Sooner People Get to Treatment Year to 1st Tx Groups 1.0 .9 .8 Cumulative Survival .7 Years from first use to 1+ years abstinence 20+ .6 .5 .4 .3 10-19* .2 .1 0.0 0-9* * p<.05 (different from 20+) 0 5 10 15 20 25 30 Source: Dennis et al., 2005

15. 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 .2 .1 0.0 0 5 10 15 20 25 Source: Dennis et al., 2005

16. 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

17. Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S. 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

18. Median Length of Stay is only 50 days Median Length of Stay Total 50 days (61,153 discharges) Less than 25% stay the 90 days or longer time recommended by NIDA Researchers LTR 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) 0 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 .

19. 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 .

20. Past Year Alcohol or Drug Abuse or Dependence 7.7% NH vs. 10.8% National Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

21. Northern - Carroll, Coos, Grafton <-US avg. 79.6 Central - Belknap, Merrimack, Strafford, Sullivan Southern - Rockingham, Cheshire, Hillsborugh New Hampshire Population and Regions • 1,235,786 people in 9,3450 square miles (137.8 people per square mile or ppsm) • Ranges for 18.8 ppsm in Coos County to 434.6 ppsm in Hillsborough County • Approximately 9% age 12-17, 4% age 18-20, 71% age 21+ • Mix of Urban, Small Urban & Rural Systems Source: U.S. Census 2000 and OAS, 2006 – 2003, 2004, and 2005 NSDUH

22. Less than 1 in 17 in US and 1 in 20 in NH get treatment Drug Treatment Alcohol Treat. Any Treatment NH Higher overall and in each region Adolescent Substance Use Disorder & Treatment Participation Rates 0 5 10 15 5.4 5.9 Drug Disorder US 8.9 6.6 New Hampshire Alcohol Disorder 7.1 10.8 Any Disorder 6.2 8.2 Northern 12.2 6.8 7.7 Central 11.4 6.5 6.6 Southern 10.1 0 5 10 15 Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

23. 269% Growth from 1992 to 1998 46% decrease in the past decade Change in NH Public Treatment Admissions: Level of Care from 1992 to 2006 1,000 909 900 758 800 709 654 649 700 560 600 513 489 488 481 OP (+136%) 416 500 364 363 IOP 328 400 (+2167%) 246 300 Residential (-50%) 200 Detox 100 (-91%) - Growth of IOP 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Source: OAS, 2006 – 1992-2006 TEDS Data

24. Change in NH Public Treatment Admissions: Referral Source from 1995 to 2006 Big Variation Caused by Changes in School, Community, & Family Referrals No. from Juv. Justice Relatively Stable Source: OAS, 2006 – 1992-2006 TEDS Data

25. Major Shift from Multiple Admission to New Admissions Change in NH Public Treatment Admissions: No. of Prior Admissions from 1995 to 2006 1,000 5 or more Tx (-97%) 900 800 4 Prior Tx (-100%) 700 600 3 Prior Tx (150%) 500 400 2 Prior Tx (175%) 300 1 Prior Tx 200 (197%) 100 No Prior Tx - (114%) 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Source: OAS, 2006 – 1992-2006 TEDS Data

26. Change in NH Public Treatment Admissions: Focal Problems from 1995 to 2006 Marijuana and Alcohol are the most common problems 700 Marijuana (189%) 600 Alcohol (148%) Hallucinogens 500 (-78%) Cocaine (50%) 400 Opioids (1750%) 300 Opioid, Psychotropics, Stimulants/Meth, and other drugs are less common but growing fast Stimulants (525%) 200 Methamphetamine (300%) 100 Psychotropics (700%) - Other (700%) 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Source: OAS, 2006 – 1992-2006 TEDS Data

27. 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

28. 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

29. 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

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

31. 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

32. Other 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

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. 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

35. 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

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

37. 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).

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

39. 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)

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

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

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

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

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

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

46. 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)

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

48. 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)

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

50. Number of Problems by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=15,254)