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Developing Effective Drug Treatment For Adolescents: Results from the Cannabis Youth Treatment (CYT) Trials

Developing Effective Drug Treatment For Adolescents: Results from the Cannabis Youth Treatment (CYT) Trials. Michael Dennis, Ph.D. Chestnut Health Systems Bloomington, IL

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Developing Effective Drug Treatment For Adolescents: Results from the Cannabis Youth Treatment (CYT) Trials

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  1. Developing Effective Drug TreatmentFor Adolescents: Results from the Cannabis Youth Treatment (CYT) Trials Michael Dennis, Ph.D. Chestnut Health Systems Bloomington, IL “Scientific Approaches to Improving Practice” Panel Presentation at the American Society of Addiction Medicine (ASAM) 2004 Annual Conference, Washington, DC, April 25, 2004. The opinions are those of the author do not reflect official positions of the government . Available on-line at www.chestnut.org/li/posters.

  2. AcknowledgementThis presentation is based on the work, input and contributions from several other people including: Nancy Angelovich, Tom Babor, Laura (Bunch) Brantley, Joseph A. Burleson, George Dent, Guy Diamond, James Fraser, Michael French, Rod Funk, Mark Godley, Susan H. Godley, Nancy Hamilton, James Herrell, David Hodgkins, Ronald Kadden, Yifrah Kaminer, Tracy L. Karvinen, Pamela Kelberg, Jodi (Johnson) Leckrone, Howard Liddle, Barbara McDougal, Kerry Anne McGeary, Robert Meyers, Suzie Panichelli-Mindel, Lora Passetti, Nancy Petry, M. Christopher Roebuck, Susan Sampl, Meleny Scudder, Christy Scott, Melissa Siekmann, Jane Smith, Zeena Tawfik, Frank Tims, Janet Titus, Jane Ungemack, Joan Unsicker, Chuck Webb, James West, Bill White, Michelle White,Caroline Hunter Williams, the other CYT staff, and the families who participated in this study. This presentation was supported by funds and data from the Center for Substance Abuse Treatment (CSAT’s) Persistent Effects of Treatment Study (PETS, Contract No. 270-97-7011) and the Cannabis Youth Treatment (CYT) Cooperative Agreement (Grant Nos. TI11317, TI11320, TI11321, TI11323, and TI11324). The opinions are those of the author and steering committee and do not reflect official positions of the government .

  3. CYT Cannabis Youth Treatment Randomized Field Trial 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 Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services

  4. Objectives • Describe the development of manual-guided, cost-effective, outpatient treatment interventions for adolescent drug abusers. • Summarize methodological advances in assessment, retention, supervision, and follow-up • Summarize evidence on their cost, effectiveness, and cost-effectiveness • Examine the diffusion of these methodological and substantive advances to the field.

  5. The Adolescent Marijuana Problem (circa 1997-1998) • Use was starting at younger ages • Was at an historically high level among adolescents • Potency increased 3-fold from 1980 to 1997 • Was three times more likely to lead to dependence among adolescents than adults • Was associated with many health, mental and behavioral problems • Was the leading substance mentioned in adolescent emergency room admissions and autopsies

  6. The State of Adolescent Treatment(circa 1997-1998) • Marijuana related admissions to adolescent substance abuse treatment increased by 115% from 1992 to 1998 • Over 80% of adolescents entering treatment in 1998 had a marijuana problem • Over 80% were entering outpatient treatment • Over 75% received less than 90 days of treatment (median of 6 weeks) • Evaluations of existing adolescent outpatient treatment suggest that adult models or less than 90 days of outpatient treatment is rarely effective for reducing marijuana use. • No empirically evaluated treatment manuals were publicly available to help expand or enhance the system

  7. Purpose of CYT • To learn more about the characteristics and needs of adolescent marijuana users presenting for outpatient treatment. • To adapt evidence-based, manual-guided therapies for use in 1.5 to 3 month adolescent outpatient treatment programs in medical centers or community based settings. • To field test the relative effectiveness, cost, cost-effectiveness, and benefit cost of five interventions targeted at marijuana use and associated problems in adolescents. • To provide validated models of these interventions to the treatment field in order to address the pressing demands for expanded and more effective services.

  8. Design • Target Population: Adolescents with marijuana disorders who are appropriate for 1 to 3 months of outpatient treatment. • Inclusion Criteria: 12 to 18 year olds with symptoms of cannabis abuse or dependence, past 90 day use, and meeting ASAM criteria for outpatient treatment • Data Sources: self report, collateral reports, on-site and laboratory urine testing, therapist alliance and discharge reports, staff service logs, and cost analysis. • Random Assignment: to one of three treatments within site in two research arms and quarterly follow-up interview for 12 months • Long Term Follow-up: under a supplement from PETSA follow-up was extended to 30 months (42 for a subsample)

  9. Two Trials or Study Arms Trial 1 Trial 2 Incremental Arm Alternative Arm Randomly Assigns to: Randomly Assigns to: MET/CBT5 MET/CBT5 Motivational Enhancement Therapy/ Motivational Enhancement Therapy/ Cognitive Behavioral Therapy (5 weeks) Cognitive Behavioral Therapy (5 weeks) MET/CBT12 ACRA Motivational Enhancement Therapy/ Adolescent Community Reinforcement Approach(12 weeks) Cognitive Behavioral Therapy (12 weeks) MDFT FSN Family Support Network Multidimensional Family Therapy Plus MET/CBT12 (12 weeks) (12 weeks) Source: Dennis et al, 2002

  10. Actual Treatment Received by Condition ACRA and MDFT both rely on individual, family and case management instead of group FSN adds multi family group, family home visits and more case management And MDFT using more family therapy MET/CBT12 adds 7 more sessions of group With ACRA using more individual therapy Source: Dennis, Godley et al, in press

  11. Less than average for 6 weeks Less than average for 12 weeks $3,495 $1,776 NTIES Est (6.7 weeks) NTIES Est.(13.1 weeks) Average Episode Cost ($US) of Treatment |--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----| $4,000 $3,322 $3,500 $3,000 $2,500 Average Cost Per Client-Episode of Care $1,984 $2,000 $1,559 $1,413 $1,500 $1,197 $1,126 $1,000 $500 $- ACRA (12.8 weeks) MET/CBT5 (6.8 weeks) MET/CBT5 (6.5 weeks) MET/CBT12 (13.4 weeks) FSN (14.2 weeks w/family) MDFT(13.2 weeks w/family) Source: French et al., 2002, 2003

  12. Implementation of Evaluation • Over 85% of eligible families agreed to participate • Quarterly follow-up of 94 to 98% of the adolescents from 3- to 12-months (88% all five interviews) • Long term follow-up completed on 90% at 30-months • Collateral interviews were obtained at intake, 3- and 6-months on over 92-100% of the adolescents interviewed • Urine test data were obtained at intake, 3, 6, 30 and 42 months 90-100% of the adolescents who were not incarcerated or interviewed by phone (85% or more of all adolescents). • Self report marijuana use largely in agreement with urine test at 30 months (13.8% false negative, kappa=.63) • 5 Treatment manuals drafted, field tested, revised, send out for field review, and finalized (10-30,000 copies of each already printed and distributed) • Descriptive, outcome and economic analyses completed Source: Dennis et al, 2002, in press

  13. Adolescent Cannabis Users in CYT were as or More Severe Than Those in TEDS* Source: Tims et al, 2002

  14. Demographic Characteristics Source: Tims et al, 2002

  15. Institutional Involvement Source: Tims et al, 2002

  16. Patterns of Substance Use 100% 73% 80% 71% 60% 40% 17% 20% 9% 0% Weekly Alcohol Weekly Weekly Significant Time Tobacco Use Cannabis Use Use in Controlled Environment Source: Tims et al, 2002

  17. Multiple Problems are the NORM Self-Reported in Past Year Source: Dennis et al, under review

  18. Co-occurring Problems are Higher for those Self-Reporting Past Year Dependence Source: Tims et al., 2002 * p<.05

  19. CYT Increased Days Abstinent and Percent in Recovery (no use or problems while in community) Source: Dennis et al., in press

  20. Similarity of Clinical Outcomes by Conditions Source: Dennis et al., in press.

  21. ACRA did better than MET/CBT5, and both did better than MDFT MET/CBT5 and 12 did better than FSN Moderate to large differences in Cost-Effectiveness by Condition Source: Dennis et al., in press

  22. Treatment Outcome Difference between intake and average of all short term follow-ups (3-12) Long Term Stability Difference between average of short term follow-ups (3-12) and long term follow-up (30) Short Term Outcome Stability Difference between average of early (3-6) and latter (9-12) follow-up interviews Evaluating the Long Term Effects of Treatment Month Z-Score Source: Dennis et al, under review, forthcoming

  23. Cumulative Recovery Pattern at 30 months:(The Majority Vacillate in and out of Recovery) Source: Dennis et al, forthcoming

  24. Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition Stability of MET/CBT-5 findings mixed at 30 months MET/CBT-5, -12 and ACRA more cost effective at 12 months $6,437 $10,405 $24,725 $27,109 $8,257 $14,222 CPPR at 30 months** Integrated family therapy (MDFT) was more cost effective than adding it on top of treatment (FSN) at 30 months Trial 1 (n=299) Trial 2 (n=297) Cost Per Person in Recovery (CPPR) $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 MET/ CBT5 MET/ CBT12 FSNM MET/ CBT5 ACRA MDFT $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 CPPR at 12 months* * P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months ** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months Source: Dennis et al., in press; forthcoming

  25. Average Cost to Society Varied More by Site than Condition UCHC, Farmington, CT (-24%, -44%) PAR, St. Petersburg, FL (-22%, -49%) CHS, Madison Co., IL (-8%, -51%) CHOP, Philadelphia, PA (+18%, -34%) $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 0 3 6 9 12 15 18 21 24 27 30 Months from Intake Source: French et al, 2003; forthcoming

  26. How does CYT compare with Regular OP/IOP: Frequency of Substance Use

  27. How does CYT compare with Regular OP/IOP: Substance Abuse/Dependence Problems

  28. Dissemination and Impact • Papers published on design, validation, characteristics, matching, clinical contrast, treatment manuals, therapist reactions, 6 month outcomes, cost, benefit cost • Papers with main clinical and cost-effectiveness findings at 12 months in press and 30 month findings being submitted this year. • Interventions being replicated as part of over four dozen studies currently or about to go into the field • 20 to 30,000 copies of each of the 5 manuals distributed to policy makers, providers, individual clinicians and training programs (via NCADI or www.chestnut.org/li/apss ) • The Global Appraisal of Individual Needs (GAIN) assessment has been used in over 70 subsequent adolescent treatment studies and combined into one large data base that will be used to support case mix adjustments, benchmarking and meta analysis • Supervision, Retention, and Follow-up models also being replicated in these adolescent treatment studies

  29. CYT was part of a Renascence of Adolescent Treatment Research/Practice From 1998 to 2002 the number of adolescent treatment studies doubled and has doubled again in the past 2 years – with over 100 currently in the field Source: Dennis &, White (2003) at www.drugstrategies.org.

  30. CSAT’s Adolescent Treatment Programs Currently Using the GAIN or CYT Txs CSAT Grantees Other Collaborators Cannabis Youth Treatment (CYT) RWJF Reclaiming Futures Program Adolescent Treatment Model (ATM) RWJF Other RWJF Grantees Strengthening Communities for Youth (SCY) Adolescent Residential Treatment (ART) NIAAA/NIDA Other Grantees Effective Adolescent Treatment (EAT) Other CSAT Grantees

  31. Conclusions • The CYT interventions provide replicable models of effective brief (1.5 to 3 month) treatments that can be used to help the field maintain quality while expanding capacity. • While a good start, the CYT interventions were still not an adequate dose of treatment for the majority of adolescents. • The majority of adolescents continued to vacillate in and out of recovery after discharge from CYT. • More work needs to be done on providing a continuum of care, longer term engagement and on going recovery management. • Adolescent treatment can be cost effective and cost beneficial to society • CYT also helped to spur a new wave of methodological improvements related to assessment, supervision, retention, and follow-up that benefit researchers, evaluators, and program planners

  32. Contact Information Michael L. Dennis, Ph.D., CYT Coordinating Center PI Lighthouse Institute, Chestnut Health Systems 720 West Chestnut, Bloomington, IL 61701 Phone: (309) 827-6026, Fax: (309) 829-4661 E-Mail: Mdennis@Chestnut.Org Manuals and Additional Information are Available at: CYT: www.health.org/govpubs or www.chestnut.org/li/bookstore PETSA: www.samhsa.gov/centers/csat/csat.html (then select PETS from program resources) APSS: www.chestnut.org/li/APSS (copies of CYT and over a dozen other adolescent treatment manuals and information on the Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE)

  33. CYT Related References Babor, T. F., Webb, C. P. M., Burleson, J. A., & Kaminer, Y. (2002). Subtypes for classifying adolescents with marijuana use disorders Construct validity and clinical implications. Addiction, 97(Suppl. 1), 58-69. Buchan, B. J., Dennis, M. L., Tims, F. M., & Diamond, G. S. (2002). Cannabis use Consistency and validity of self report, on-site urine testing, and laboratory testing. Addiction, 97(Suppl. 1), 98-108. Dennis, M. L., Babor, T., Roebuck, M. C., & Donaldson, J. (2002). Changing the focus The case for recognizing and treating marijuana use disorders. Addiction, 97 (Suppl. 1), S4-S15. Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003). The need for developing and evaluating adolescent treatment models. In S.J. Stevens & A.R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary Models from a National Evaluation Study (pp. 3-34). Binghamton, NY: Haworth Press and 1998 NHSDA. Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (in press). The Cannabis Youth Treatment (CYT) Study: Main Findings from Two Randomized Trials. Journal of Substance Abuse Treatment. Dennis, M. L., Godley, S. and Titus, J. (1999). Co-occurring psychiatric problems among adolescents: Variations by treatment, level of care and gender. TIE Communiqué (pp. 5-8 and 16). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Dennis, M. L. and McGeary, K. A. (1999). Adolescent alcohol and marijuana treatment: Kids need it now. TIE Communiqué (pp. 10-12). Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Dennis, M. L., Titus, J. C., Diamond, G., Donaldson, J., Godley, S. H., Tims, F., Webb, C., Kaminer, Y., Babor, T., Roebuck, M. C., Godley, M. D., Hamilton, N., Liddle, H., Scott, C. K., & CYT Steering Committee. (2002). The Cannabis Youth Treatment (CYT) experiment Rationale, study design, and analysis plans. Addiction, 97 (Suppl. 1), S16-S34. 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., White,M.A., Titus, J.C. & Godley, M.D. (in press). The effectiveness of adolescent substance abuse treatment: a brief summary of studies through 2002. (prepared for Drug Strategies adolescent treatment handbook). Bloomington, IL: Chestnut Health Systems. Diamond, G., Leckrone, J., & Dennis, M. L. (In press). The Cannabis Youth Treatment study Clinical and empirical developments. In R. Roffman, & R. Stephens, (Eds.) Cannabis dependence Its nature, consequences, and treatment . Cambridge, UK Cambridge University Press. Diamond, G., Panichelli-Mindel, S. M., Shera, D., Dennis, M. L., Tims, F., & Ungemack, J. (in press). Psychiatric syndromes in adolescents seeking outpatient treatment for marijuana with abuse and dependency in outpatient treatment. Journal of Child and Adolescent Substance Abuse.

  34. CYT Related References - continued Godley, M.D., Kahn, J.H., Dennis, M.L., Godley, S.H., & Funk, R.R. (in press). The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment. Psychology of Addictive Behavior. Godley, S. H., White, W. L., Diamond, G., Passetti, L., & Titus, J. (2001). Therapists' reactions to manual-guided therapies for the treatment of adolescent marijuana users. Clinical Psychology Science and Practice, 8(4), 405-417. Godley, S. H., Meyers, R. J., Smith, J. E., Godley, M. D., Titus, J. M., Karvinen, T., Dent, G., Passetti, L., & Kelberg, P. (2001). The Adolescent Community Reinforcement Approach (ACRA) for adolescent cannabis users (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 4). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Hamilton, N., Brantley, L., Tims, F., Angelovich, N., & McDougall, B. (2001). Family Support Network (FSN) for adolescent cannabis users (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 3). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Jensen, K. A. (2001). The effects of adolescent peer-based intervention Contextual influence of peers during cannabis treatment. University of South Florida. Liddle, H. A. (2002). Multidimensional Family Therapy (MDFT) for adolescent cannabis users (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 5). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Petry, N. M., & Tawfik, Z. (2001). A comparison of problem gambling and non-problem gambling youth seeking treatment for marijuana abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 40(11), 1324-1331. Roebuck, M. C., French, M. T., & Dennis, M. L. (2004). Adolescent marijuana use and school attendance. Economics of Education Review, 23(2), 145-153. Sampl, S., & Kadden, R. (2001). Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users 5 Sessions (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 1). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Tims, F. M., Dennis, M. L., Hamilton, N., Buchan, B. J., Diamond, G. S., Funk, R., & Brantley, L. B. (2002). Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment . Addiction, 97, 46-57. Titus, J. C., & Dennis, M. L. (in press). Cannabis Youth Treatment (CYT) Overview and summary of preliminary findings. H. A. Liddle, & C. L. Rowe (Eds.), Treating adolescent substance abuse State of the science . Cambridge, UK Cambridge University Press. Titus, J. C., Dennis, M. L., White, W. L., Scott, C. K., & Funk, R. R. (2003). Gender differences in victimization severity and outcomes among adolescents treated for substance abuse. Journal of Child Maltreatment, 8, 19-35. Webb, C., Scudder, M., Kaminer, Y., Kadden, R., & Tawfik, Z. (2002). The MET/CBT 5 Supplement 7 Sessions of Cognitive Behavioral Therapy (CBT 7) for adolescent cannabis users (Cannabis Youth Treatment (CYT) Manual Series, No. Volume 2). Rockville, MD Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.

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