Michael L. Dennis, Rodney R. Funk & Christy K Scott Chestnut Health Systems,

1. The Cycle of Use, Treatment, Incarceration and Recovery after Adolescent Treatment and the Potential for Further Intervention Michael L. Dennis, Rodney R. Funk & Christy K Scott Chestnut Health Systems, Normal & Chicago, IL Presentation at the Joint Meeting on Adolescent Treatment Effectiveness (JMATE), Baltimore, MD, December 14-16, 2010.

2. Acknowledgement • This presentation was supported by funds from the National Institute on Drug Abuse (NIDA) grant R37-DA11323. • It uses data provided by 17 Center for Substance Abuse Treatment (CSAT) grantees: TI-11317, TI-11320, TI-11321, TI-11323, TI-11324, TI-11422, TI-11423, TI-11424, TI-11432, TI-11894, TI-11892, TI-13344, TI-13354, TI-13356, TI-14252, TI-14272, TI-14376, TI-16400 • The opinions are those of the authors do not reflect official positions of the government. • Available on line at www.chestnut.org/LI/Posters or by contacting Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761, phone 309-451-7801, fax 309-451-7765, e-Mail: mdennis@chestnut.org • Questions about the GAIN can also be sent to gaininfo@chestnut.org

3. Why Focus on Adolescents? • Over 90% of people with dependence start using under the age of 18 and met abuse or dependence criteria by age 20 • People who start using under age 15 use 60% more years than those who start over age 18 • Entering treatment within the first 9 years of initial use leads to 57% fewer years of substance use than those who do not start treatment until after 20 years of use • Relapse is common and it takes an average of 3 to 4 treatment admissions over 8 to 9 years before half reach recovery • Of those with abuse/dependence, 2/3rds eventually reach a state of recovery • Monitoring and early re-intervention with adults has been shown to cut the time from relapse to readmission by 65%, increase abstinence and improve long term outcomes Source: Dennis et al., 2005, 2007; Scott & Dennis 2009

4. Objectives • Describe how adolescent cycle through periods of using, treatment, incarceration, and recovery • Examine the predictors of initiating and staying in recovery • Compare transition rates of adolescents with adults • Discuss the implications for potential interventions

5. Data Source • Recruited 1037 youth between 2000 and 2006 from 17 CSAT grants in 13 cities: Baltimore, MD, Bloomington, IL, Hartford, CT, Iowa City, IA, Lynchburg, VA, New York, NY, Oakland, CA, Philadelphia, PA, Phoenix, AZ, Richmond, VA, St. Petersburg, FL, San Diego, CA, Tucson, AZ • Follow-up done at 3, 6, 9, & 12 months (82-92% or more follow-up at each wave) • Focus here is on 1,895 observations for quarterly transitions after treatment (3 to 6, 6 to 9, or 9 to 12 months) • Assessments included the Global Appraisal of Individual Needs (GAIN)

6. Participant Characteristics

7. Method • At each interview wave adolescents were classified into one of 4 states: • in the community using, • in a controlled environment, • in treatment, • In recovery in the community • Describe the probability of transitioning to a different state from one interview to the next • Evaluate the significant predictors of movement towards recovery (vs. use) using manual stepwise in SPSS and Hedeker’s mixed nominal (MIXNO) model to control for repeated observations on people

8. P not the same in both directions 3% 5% 10% 20% 24% 12% 27% 7 % 7% 19% 26% 7% Treatment is the most likely path to recovery The Cyclical Course : Adolescents Movement in all possible directions Incarcerated (46% stable) In the In Recovery Community (62% stable) Using (75% stable) Avg of 39% change status each quarter In Treatment (48% stable) Source: 2006 CSAT AT data set

9. The Cyclical Course : Adolescents • Probability of Going from Use to Early “Recovery” (+ good) • Age (0.8) + Female (1.7), • Frequency Of Use (0.23) + Non-White (1.6) • + Self efficacy to resist relapse (1.4) • + Substance Abuse Treatment Index (1.96) In the 12% In Recovery Community (62% stable) Using 27% (75% stable) Probability of from Recovery to “Using” (+ good) - Freq. Of Use (0.0002) + Initial Weeks in Treatment (1.03) - Illegal Activity (0.70) + Treatment Received During Quarter (2.00) - Age (0.81) + Recovery Environment (r)* (1.45) + Positive Social Peers (r)** (1.43) • * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home • ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.

10. The Cyclical Course : Adolescents • Probability of Going from Use to “Treatment” (+ good) • Age (0.7) + Times urine Tested (1.7), • + Treatment Motivation (1.6) • + Weeks in a Controlled Environment (1.4) In the Community Using (75% stable) 7% In Treatment (48 v 35% stable) Source: 2006 CSAT AT data set

11. Probability of Going to Using vs. Early “Recovery” (+ good) • - Baseline Substance Use Severity (0.74) + Baseline Total Symptom Count (1.46) • - Past Month Substance Problems (0.48) + Times Urine Screened (1.56) • - Substance Frequency (0.48) + Recovery Environment (r)* (1.47) • + Positive Social Peers (r)** (1.69) In the In Recovery Community (62% stable) Using (75% stable) 26% 19% • * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home • ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity. In Treatment (48 v 35% stable) Source: 2006 CSAT AT data set The Cyclical Course : Adolescents

12. Probability of Going to Using vs. Early “Recovery” (+ good) + Recovery Environment (r)* (3.33) The Cyclical Course : Adolescents Incarcerated (46% stable) 10% 20% In the In Recovery Community (62% stable) Using (75% stable) * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home Source: 2006 CSAT AT data set

13. Risk Factors Older Male Caucasian Substance problems (intake and past month) Substance use frequency Illegal activity Protective Factors Younger Female Racial minority Initial treatment length Intake severity Recent treatment Self-efficacy to resist relapse Number of drug screens Treatment motivation Weeks of controlled environment Positive social peers Positive recovery environment Risk and Protective Factors Associated with Transitioning to/Remaining in Recovery

14. 4% 3% 13% 23% 8% 10% 24% 7% 6% 25% 35% 10% Again the Probability of Entering Recovery is Higher from Treatment The Cyclical Course : Adults 34% Changed Status in an Average Quarter Incarcerated (56% stable) In the In Recovery Community (58% stable) Using (75% stable) In Treatment (32% stable) Source: Riley, Scott & Dennis, 2008

15. Comparison with Adults (Riley et al 2008) • Adolescents were more likely than adults to: • Go from incarceration to treatment (24% vs. 9%, OR=3.6) • Stay in treatment 90 or more days (48% vs. 35%, OR=2.0) • Go from using to incarceration (5% vs. 4%, OR=1.2) • Go from using to recovery (12% vs. 10%, OR=1.2)

16. Comparison with Adults (Riley et al 2008) • Adolescents were less likely than adults to • Go from use to treatment (7% vs. 10%, OR=0.7) • Go from treatment to using (26% vs. 35%, OR=0.6) • Go from treatment to recovery (19% vs. 25%, OR=0.7) • Go from incarceration to recovery (10% vs. 13%, OR=0.7)

17. Implications for Program Planning • More proactive outreach • Continue diversion from juvenile justice system • More developmentally and effective treatment models • More assertive continuing care after treatment and detention including linkage to positive recovery environment and social • Need for longer term monitoring for relapse and early re-intervention to be a standard component of care like it is for other chronic conditions

18. Limitations and Next Steps • Large sample size, but could still be more diverse • Limiting to equal intervals excluded many transitions • Only examining the first 9 months after treatment (vs adult studies going out 2-4 years) • Based only on self report • Proposing to use larger samples in 2010 data set to explore whether these findings are replicated across 280 sites on over 25,000 youth with more diverse characteristics

19. References Dennis, M.L., Foss, M.A., & Scott, C.K (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612 Dennis, M. L., Scott, C. K. (2007). Managing Addiction as a Chronic Condition. Addiction Science & Clinical Practice , 4(1), 45-55. Dennis, M. L., Scott, C.K, & Funk, R. (2003). An experimental evaluation of Recovery Management Checkups (RMC) with chronic substance users. Evaluation and Program Planning, 26 (3), 339-352. 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. Hedeker, D. (1999). MIXNO: A computer program for nominal mixed-effects regression. Journal of Statistical Software, 4, 1-92. Riley, B.B.,, Scott, C.K, & Dennis, M.L. (2008). The effect of recovery management checkups on transitions from substance use to substance abuse treatment and from treatment to recovery. Poster presented at the UCLA Center for Advancing Longitudinal Drug Abuse Research Annual Conference, August 13-15, 2008, Los Angless, CA. www.caldar.org . Scott, C. K., & Dennis, M. L. (2009). Results from Two Randomized Clinical Trials evaluating the impact of Quarterly Recovery Management Checkups with Adult Chronic Substance Users. Addiction, 104, 959-971. Scott, C. K., & Dennis, M. L. (in press). Recovery management checkups with adult chronic substance users. In Kelly, J.F., and White, W.L. (Eds), Addiction Recovery Management: Theory, Research, and Practice. New York, NY: Springer Scott, C. K., Dennis, M. L., & Foss, M. A. (2005). Utilizing recovery management checkups to shorten the cycle of relapse, treatment re-entry, and recovery. Drug and Alcohol Dependence, 78(3), 325-338 Scott, C. K., Dennis, M. L., Laudet, A., Funk R. & Simeone, R., & (in press). Surviving Drug Addiction: Do treatment and abstinence reduce mortality? American Journal of Public Health. Scott, C. K., Foss, M. A., & Dennis, M. L. (2005). Pathways in the relapse, treatment, and recovery cycle over three years. Journal of Substance Abuse Treatment, 28, S61-S70.