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Emily E. Tanner-Smith Mark W. Lipsey Sandra J. Wilson

Comparative Effectiveness of Substance Abuse Treatment Programs for Adolescents: Results from Three Meta-analyses. Emily E. Tanner-Smith Mark W. Lipsey Sandra J. Wilson Peabody Research Institute Vanderbilt University. Acknowledgements.

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Emily E. Tanner-Smith Mark W. Lipsey Sandra J. Wilson

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  1. Comparative Effectiveness of Substance Abuse Treatment Programs for Adolescents:Results from Three Meta-analyses Emily E. Tanner-SmithMark W. LipseySandra J. Wilson Peabody Research InstituteVanderbilt University

  2. Acknowledgements • This study was supported by contracts 270-2003-00006 & HHSS270200700004C from the Center for Substance Abuse Treatment (CSAT) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA); Z-Tech subcontract S-2060-55-VU; and contract HHSN275200900598P from NIAAA. Opinions expressed in this presentation those of the authors and do not necessarily reflect the opinions or policies of CSAT, NIAAA, their staff, or employees. • No conflicts of interest to disclose

  3. Figure 1.1. Dependence on or Abuse of Alcohol and Illicit Drugs among Youths Aged 12 to 17: 2002–2009 National Survey on Drug Use and Health

  4. Figure 1.2. Adolescent Treatment Admissions by Primary Substance: 1996-2006 Treatment Episode Data Set

  5. Background • With so many adolescents enrolled in formal substance abuse treatment, a critical question is whether these programs are effective in reducing substance use • Robust evidence of beneficial treatment effects in meta-analyses of adult-only or mixed-age samples • Most prior reviews of treatment effects for adolescent samples tend to be narrative, limited to only a few specific treatment types, or focus only on randomized controlled trials

  6. Research Questions • What is the comparative effectiveness of different types of treatment programs for adolescents with substance use disorders? • How does substance use change after adolescents enter into substance abuse treatment? • What methodological, participant, and treatment characteristics influence these changes? • How do results from research-oriented treatment programs compare with results from more routine, real-world treatment programs?

  7. The Project • Three-pronged approach to summarize the effectiveness of treatment programs for adolescents with substance abuse issues • 1. Meta-analysis of experimental & quasi-experimental studies comparing adolescents in a treatment group with a comparison group • 2. Meta-analysis of pretest-posttest changes in substance use based on single group arms from experimental & quasi-experimental studies • 3. Analysis of aggregate data from treatment providers using the GAIN instrument and reporting data to Chestnut Health Systems

  8. A Meta-analysis of Experimental and Quasi-Experimental Studies Emily E. Tanner-Smith & Mark W. Lipsey Peabody Research Institute Vanderbilt University

  9. The Meta-analysis • Comprehensive systematic review of substance abuse treatment programs aimed at reducing adolescent substance use. Eligibility requirements: • Client-oriented programs targeting substances other than tobacco/caffeine • Reporting of results for adolescents age 12-20 exhibiting clinical levels of substance abuse or dependence • Experimental and quasi-experimental research designs • Published 1980 or after; reported in English

  10. Review Methods • Comprehensive search for studies 1980-2008 • Major electronic databases: Dissertation Abstracts, ERIC, PsychInfo, PubMed, Social Services Abstracts, Sociological Abstracts • Additional ‘grey’ literature searches: NCJRS, CPDD presentations, CRISP, JMATE presentations, contact with researchers and providers, citations from study reports • Four trained coders completed coding on 500+ items related to general study context, methods, participants, treatments, outcomes

  11. Meta-analytic Sample • 260 effect sizes representing posttest differences in substance use outcomes between non-residential treatment and comparison groups • Originate from 48 experimental or quasi-experimental studies • Represent 79 different treatment-comparison group combinations • 105 alcohol outcomes, 41 marijuana/cannabis outcomes, 86 mixed substance use outcomes (e.g., SFS from GAIN), 28 other specific substance use outcomes (e.g., cocaine)

  12. Characteristics of the Studies Table 2.1. Weighted Means and Ranges of Study Characteristics (n = 260)

  13. Characteristics of the Study Participants Table 2.2. Weighted Means and Ranges of Study Participant Characteristics (n = 260)

  14. Non-Residential Treatment Types • Cognitive behavioral therapy (CBT) • No branded programs; all generic cognitive behavioral therapy programs (n = 46; k = 15) • Family therapy • Functional Family Therapy (n = 15; k = 5) • Multidimensional Family Therapy (n = 20; k = 7) • Family Support Network (n = 4; k = 2) • Multisystemic Therapy (n = 26; k = 5) • Seven-Challenges (n = 2; k = 1) • Other generic family therapy programs (n = 21; k = 5) • Note: n = number of effect sizes; k = number of unique treatment-comparison combinations.

  15. Non-Residential Treatment Types (cont.) • Individual counseling (IC) • No branded programs; all generic counseling programs (n = 29; k = 8) • Motivational interviewing/motivational enhancement therapy (MET) • Motivational interviewing programs (n = 34; k = 7) • Motivational enhancement therapy (n = 36; k = 10) • MET + CBT (MET/CBT) • Branded MET/CBT-5 (n = 6; k = 3) • Branded MET/CBT-12 (n = 12; k = 6) • Unbranded generic MET/CBT (n = 10; k = 6)

  16. Non-Residential Treatment Types (cont.) • Psychoeducational therapy (PET) • Unbranded psychoeducational curriculum (n = 17; k = 7) • Other generic educational programs (n = 38; k = 12) • No treatment (No Tx) • No treatment, assessment only, and delayed control groups (n = 70; k = 13) • Other focal type • Other mixed treatment types with few effect sizes (n = 120; k = 39) • E.g., behavioral/contingency management, generic group counseling, skills training, vocational counseling, pharmacological, drug court, multi-service packages

  17. Treatment Type Combinations Table 2.3. Number of Effect Sizes and Unique Groups Comparing Different Treatment Types • Note: Number of unique group comparisons shown in parentheses. Numbers do not sum to total because some treatment groups had multiple focal treatment types.

  18. Comparative Treatment Effectiveness • Comparative treatment effectiveness examined for all direct pairwise combinations of most common treatment types (e.g., CBT vs. Family, CBT vs. MET-CBT) • Meta-regression models with robust standard errors used to calculate covariate adjusted posttest effect sizes • All models adjusted for method and subject characteristics that may confound group differences

  19. Note: Means above the red line indicate CBT produced worse outcomes than the comparison type; means below indicate CBT produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.1. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for CBT

  20. Note: Means above the red line indicate FAM produced worse outcomes than the comparison type; means below indicate FAM produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.2. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for Family Therapy

  21. Note: Means above the red line indicate IC produced worse outcomes than the comparison type; means below indicate IC produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.3. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for Individual Counseling

  22. Note: Means above the red line indicate MET produced worse outcomes than the comparison type; means below indicate MET produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.4. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for MET

  23. Note: Means above the red line indicate MET-CBT produced worse outcomes than the comparison type; means below indicate MET-CBT produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.5. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for MET-CBT

  24. Note: Means above the red line indicate PET produced worse outcomes than the comparison type; means below indicate PET produced better outcomes. All estimates adjusted for method and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies. Figure 2.6. Mean Adjusted Posttest Effect Sizes and 95% Confidence Intervals for PET

  25. Summary and Conclusions • Most group comparison studies were relatively recent, conducted in the United States, and published in journal articles • Although many studies compared focal treatment programs to no treatment, treatment as usual, or psycho-educational therapy control conditions; many compared two treatment programs to each other • Several treatment-treatment combinations (e.g., Family vs. MET) had no direct pairwise evidence or too few comparisons available to make reliable statements of their comparative effectiveness

  26. Summary and Conclusions (cont.) • Using direct pairwise evidence for the different treatment-treatment combinations available: • Family therapy & MET were more effective than all other treatment types with which they were compared • CBT and MET-CBT also tended to be more effective than minimal treatment exposure arms • Individual counseling was less effective than all other treatment types with which it was compared • PET, No treatment, and all other treatment programs tended to be less effective than other program types

  27. A Meta-analysis of Pretest-Posttest Changes in Substance Use Emily E. Tanner-Smith Peabody Research Institute Vanderbilt University

  28. The Meta-analysis • Comprehensive systematic review of substance abuse treatment programs aimed at reducing adolescent substance use. Eligibility requirements: • Client-oriented programs targeting substances other than tobacco/caffeine • Reporting of results for adolescents age 12-20 exhibiting clinical levels of substance abuse or dependence • Group arms from experimental and quasi-experimental studies • Published 1980 or after; reported in English

  29. Meta-analytic Sample • 311 effect sizes representing pretest-posttest changes (improvements) in substance use outcomes for non-residential treatment and comparison groups • Originate from 44 experimental and quasi-experimental, and studies • Represent 98 different individual treatment or comparison group arms • 139 alcohol outcomes, 40 marijuana/cannabis outcomes, 105 mixed substance use outcomes, 27 other specific substance

  30. Characteristics of the Studies Table 3.1. Weighted Means and Ranges of Study Characteristics (n = 311)

  31. Characteristics of the Study Participants Table 3.2. Weighted Means and Ranges of Study Participant Characteristics (n = 311)

  32. Non-Residential Treatment Types Table 3.3. Most Common Focal Treatment Types • Note: Numbers do not sum to 311 because some studies had multiple focal treatment types.

  33. Average Pretest-Posttest Changes Table 3.4. Weighted Means, 95% Confidence Intervals, and Between Studies Variance Components for Pretest-Posttest Effect Sizes, by Type of Substance Use Outcome • Note: Confidence intervals based on robust standard errors that account for clustering within studies.

  34. Method Factors Associated with Improved Outcomes Table 3.5. Unstandardized Coefficients, 95% Confidence Intervals, and Standardized Coefficients from Meta-Regression Models Predicting Pretest-Posttest Effect Sizes with Study Method Characteristics • Note: Confidence intervals based on robust standard errors that account for clustering within studies. Regression model also controls for type of drug use outcome and group arm position in database. † p < .10.

  35. Participant Factors Associated with Improved Outcomes Table 3.6. Unstandardized Coefficients, 95% Confidence Intervals, and Standardized Coefficients from Meta-Regression Models Predicting Pretest-Posttest Effect Sizes with Study Participant Characteristics • Note: Confidence intervals based on robust standard errors that account for clustering within studies. Regression model also controls for type of drug use outcome, group arm position in database, and all method characteristics shown in Table 3.5.

  36. Treatment Characteristic Factors Associated with Improved Outcomes Table 3.7. Unstandardized Coefficients, 95% Confidence Intervals, and Standardized Coefficients from Meta-Regression Models Predicting Pretest-Posttest Effect Sizes with Treatment Program Characteristics • Note: Confidence intervals based on robust standard errors that account for clustering within studies. Regression model also controls for type of drug use outcome, group arm position in database, all method characteristics shown in Table 3.5, and all participant characteristics shown in Table 3.6. * p < .05.

  37. Figure 3.1. Adjusted Pretest-Posttest Effect Sizes by Treatment Type • Note: Means to the right of the red line indicate a beneficial improvement in substance use over time (i.e., lower substance use, higher abstinence, etc.) . Estimates adjusted for drug outcome type, method, and participant characteristics. Confidence intervals based on robust standard errors that account for clustering within studies.

  38. Summary and Conclusions • After entry into non-residential substance abuse treatment programs, most adolescents showed significant reductions in their substance use • The smallest observed reductions were for alcohol and other specific substance use outcomes (e.g., cocaine use) • Longer treatment duration was associated with less improvement in substance use outcomes over time (i.e., smaller pretest-posttest changes)

  39. Summary and Conclusions (cont.) • Relative strength of improvement in substance use varied by focal treatment type: • Participants in family therapy, CBT, and MET/CBT programs exhibited the largest improvements in substance use over time • Participants in individual counseling and no treatment control groups exhibited the smallest improvements in substance use outcomes over time • However, participants in all types of treatment programs reported significant reductions in substance use over time (even no treatment or practice as usual conditions)

  40. Examining the Effectiveness of Adolescent Substance Abuse Treatment Using the Global Appraisal of Individual Needs (GAIN) Monitoring and Measuring System Sandra Jo Wilson Peabody Research Institute Vanderbilt University

  41. Presentation Overview • Brief discussion of the GAIN and the kinds of adolescent substance abuse treatment programs that use the GAIN instrument. • Using the GAIN as an additional source of information about the effectiveness of substance abuse treatment for adolescents. • Identify characteristics of the adolescents in treatment and characteristics of the treatment programs that are associated with greater (or smaller) reductions in substance abuse.

  42. Global Appraisal of Individual Needs (GAIN) • The GAIN is a standardized interview designed by Dr. Michael Dennis and his colleagues at Chestnut Health Systems (Dennis et al., 2003). • The GAIN can be used to support: • Diagnosis, placement, treatment planning, and outcome monitoring • Program evaluation and clinical research • Designed to be collected at intake, and at 3, 6, 9, and 12 months post-intake. • For this project, we are using a de-identified dataset of both outpatient and residential treatment programs for adolescents.

  43. Outpatient Programs • Funded under several CSAT funding initiatives (e.g., EAT, SCY, and CYT). • 103 outpatient treatment programs serving over 9,000 adolescent clients (27 represented in the meta-analysis). • Predominantly male clients (average 73% male across programs). • Mixed ethnic backgrounds: • Across all programs, 48% Caucasian, 22% Hispanic, 15% African American, and 15% other minority. • Average age at intake was 16.

  44. Substance Use Histories for Clients in Outpatient Programs • Adolescents presented with multiple substance use histories, with 82% presenting with alcohol use, 90% presenting with marijuana use, and 59% presenting with illicit drugs other than alcohol or marijuana. • Adolescents’ primary substance was predominantly marijuana (61%). • Significant proportions of clients had antisocial/delinquent histories and/or mental health histories. • 45% with court or probation contact • 63% with co-occurring mental health symptoms

  45. Outpatient Treatment Types Table 4.1. Outpatient Treatment Types and Dosage Information

  46. Outpatient Treatment Types (cont.) Table 4.1 (cont). Outpatient Treatment Types and Dosage Information

  47. Targeting of Programs • Nearly all treatment programs served high proportions of adolescents who used alcohol and marijuana. • ACRA, Thunder Rd., and EMPACT served proportionately larger numbers of adolescents who used amphetamines, crack/ cocaine, or opiates. • ACRA served a high proportion of amphetamine users. • Thunder Rd. served a high proportion of opiate users. • EMPACT served a high proportion of crack/cocaine users. • In general, the programs in the other group tended to serve adolescents with greater substance use problems and higher use frequencies.

  48. Substance Use Outcomes • Composite variable indexing substance issues, abuse, dependence, and problems, frequency of use, and abstinence. (Substance Use Problems) • Not drug-specific • Used 6-month post-intake outcomes, providing that it occurred after treatment and had less than 50% attrition. • For longer programs, 9- or 12-month outcomes were used. • For high attrition programs 3-month outcomes were used. • Across all programs, substance use problems were significantly lower (better) at the posttest than at intake.

  49. Disclaimer • Keep in mind that we are talking about reductions in substance use problems from intake to follow-up and (on the next few slides) identifying factors that are associated with those changes. • Without a control group, we cannot know definitively whether the factors caused the improvements we observed. • It is possible that adolescents in treatment programs not part of this study, or adolescents receiving no treatment at all, would show similar improvements. • Some unmeasured characteristic of treatments or adolescents that overlaps with the variables we have in the dataset may be responsible for the improvements.

  50. Factors Associated with Improved Outcomes • Programs with more attrition exhibited larger reductions in substance use problems (b = -.26*). • Adolescents with more serious problems failed to participate in the follow-up interviews. • Programs with larger proportions of males exhibited smaller reductions in substance use problems (b= .19*). • Programs with larger proportions of clients with mental health histories exhibited smaller reductions in substance use problems (b= .37*). • Programs with higher proportions of clients with alcohol use problems exhibited smaller reductions in substance use problems (b=.21*). Note: regression coefficients are standardized; *p < .05.

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