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Cannabis Youth Treatment (CYT) Trials: 12 and 30 Month Main Findings. Michael Dennis, Ph.D. (On Behalf of the CYT Steering Committee) Chestnut Health Systems Bloomington, IL

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Cannabis youth treatment cyt trials 12 and 30 month main findings l.jpg

Cannabis Youth Treatment (CYT) Trials: 12 and 30 Month Main Findings

Michael Dennis, Ph.D.

(On Behalf of the

CYT Steering Committee)

Chestnut Health Systems

Bloomington, IL

Presentation for SAMHSA Center for Substance Abuse Treatment (CSAT) Effective Adolescent Treatment (EAT) Grantee meeting, Baltimore, MD, November 3-5, September 19, 2003. The opinions are those of the author do not reflect official positions of the government . Available on-line at www.chestnut.org/li/posters.


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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 .


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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


Marijuana l.jpg

Marijuana

  • Use is starting at younger ages

  • Is at an historically high level among adolescents

  • Potency increased 3-fold from 1980 to 1997

  • Is three times more likely to lead to dependence among adolescents than adults

  • Is associated with many health, mental and behavioral problems

  • Is the leading substance mentioned in adolescent emergency room admissions and autopsies


Treatment l.jpg

Treatment

  • 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% are entering outpatient treatment

  • Over 75% receive less than 90 days of treatment (median of 6 weeks)

  • Evaluations of existing adolescent outpatient treatment suggest that last than 90 days of outpatient treatment is rarely effective for reducing marijuana use.


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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.


Design l.jpg

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)


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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


Contrast of the treatment structures l.jpg

2

2

2

10

6

3

10

10

Type of Service

MET/

CBT5

MET/

CBT12

FSN

ACRA

MDFT

2

3

4

2

6

6

5

12

22

14

15

As needed

As needed

As needed

5

5

6-7

12-13

12

12

22+

22+

12-13

12-13

14+

14+

15+

12-13

15+

Contrast of the Treatment Structures

Individual Adolescent Sessions

CBT Group Sessions

Individual Parent Sessions

Family Sessions/Home Visits

Parent Education Sessions

Total Formal Sessions

Case management/

Other Contacts

Total Expected Contacts

Total Expected Hours

Total Expected Weeks

Source: Diamond et al, 2002


Actual treatment received by condition l.jpg

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 et al, under review


Average episode cost us of treatment l.jpg

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


Implementation of evaluation l.jpg

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 and 91% (of 116 subsample) at 42-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, under review


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Adolescent Cannabis Users in CYT were

as or More Severe Than Those in TEDS*

Source: Tims et al, 2002


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Demographic Characteristics

Source: Tims et al, 2002


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Institutional Involvement

Source: Tims et al, 2002


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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


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Multiple Problems are the NORM

Self-Reported in Past Year

Source: Dennis et al, under review


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Co-occurring Problems are Higher for those Self-Reporting Past Year Dependence

Source: Tims et al., 2002 * p<.05


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CYT Increased Days Abstinent and Percent in Recovery (no use or problems while in community)

Source: Dennis et al., under review


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Similarity of Clinical Outcomes

by Conditions

Source: Dennis et al., under review


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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., under review


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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


Change in substance frequency scale in cyt trial 1 incremental arm l.jpg

  • Treatment Outcome:

  • Use reduced (-34%)

  • No Sig. Dif. by condition

  • Long Term Stability:

  • - Use increases (+64%)

  • No Sig. Dif. by condition

Short Term Stability:

- Outcomes stable (-1%)

- No Sig. Dif. by condition

Change in Substance Frequency Scale in CYT Trial 1: Incremental Arm

Months from Intake

Source: Dennis et al, forthcoming


Change in number of substance problems in cyt trial 1 incremental arm l.jpg

  • Treatment Outcome:

  • Problems reduced (-46%)

  • Sig. Dif. by condition

  • (-50% vs. –33% vs. –51%)

  • Short Term Stability:

  • Further reductions (-25%)

  • No difference by condition

  • Long Term Stability:

  • Problems increase (+17%)

  • Sig. Dif. by condition

  • (+37% vs +10% vs +7%)

Change in Number of Substance Problems in CYT Trial 1: Incremental Arm

Months from Intake

Source: Dennis et al, forthcoming


Change in substance frequency scale in cyt trial 2 alternative arm l.jpg

  • Treatment Outcome:

  • Use reduced (-35%)

  • No Sig. Dif. by condition

  • Short Term Stability:

  • Further reductions (-6%)

  • Sig. Dif. by condition

  • (+4% vs. –10% vs. –11%)

  • Long Term Stability:

  • - Outcomes stable (+20%)

  • No Sig. Dif. by condition

Change in Substance Frequency Scale inCYT Trial 2: Alternative Arm

Months from Intake

Source: Dennis et al, forthcoming


Change in number of substance problems in cyt trial 2 alternative arm l.jpg

Treatment Outcome:

- Problems reduced (-43%)

- No difference by condition

  • Long Term Stability:

  • Outcomes stable (+7%)

  • No Sig. Dif. by condition

Short Term Stability:

- Outcomes stable (-8%)

- No Sig. Dif. by condition

Change in Number of Substance Problems inCYT Trial 2: Alternative Arm

Months from Intake

Source: Dennis et al, forthcoming


Percent in past month recovery no use or problems while living in the community l.jpg

Percent in Past Month Recovery (no use or problems while living in the community)

Source: Dennis et al, forthcoming


Cumulative recovery pattern at 30 months the majority vacillate in and out of recovery l.jpg

Cumulative Recovery Pattern at 30 months:(The Majority Vacillate in and out of Recovery)

Source: Dennis et al, forthcoming


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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., under review; forthcoming


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Reduction in Average Cost to Society in

CYT Trial 1: Incremental Arm

Includes the cost of CYT Treatment

Reductions

(-23%) in Average Cost to Society offset Treatment Costs within 12 months

Further Reductions

(-47%) occurred out to 30 months

Source: French et al, 2003; forthcoming


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Reduction in Average Cost to Society in

CYT Trial 2: Alternative Arm

Includes the cost of CYT Treatment

Average Cost to Society goes up then down and does not offset Tx Costs within 12 months (+7%)

Further Reductions occurred out to 30 months

(-40%)

Source: French et al, 2003; forthcoming


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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


Reprise of clinical outcomes l.jpg

Reprise of Clinical Outcomes

  • Co-occurring problems were the norm and varied with substance use severity.

  • In Trial 1, FSN and MET/CBT5 were relatively more effective than MET/CBT12 in reducing substance abuse/dependence problems (treatment effect); With FSN doing better at holding its gains out to 30 months

  • In Trial 2, ACRA and MDFT were more effective than MET/CBT5 in reducing substance abuse/dependence problems (treatment effect) and short term stability on substance use; With ACRA and MDFT doing better at holding their gains out to 30 months.

  • These were not easily explained simply by dosage or level of family therapy and there was no evidence of iatrogenic effects of group therapy.

  • While more effective than many earlier outpatient treatments, 2/3rds of the CYT adolescents were still having problems 12 months latter, 4/5ths were still having problems 30 months latter.


Reprise of economic outcomes l.jpg

Reprise of Economic Outcomes

  • There were considerable differences in the cost of providing each of the interventions.

  • MET/CBT-5, -12 and ACRA were the most cost effective at 12 months, though the stability of the MET/CBT findings were mixed at 30 months.

  • Reductions in Average Quarterly Cost to Society offset the cost of treatment within 12 months in trial 1 and with 30 months in trial 2.

  • At 12 months the MET/CBT5 intervention clearly had the highest rate of return.

  • By 30 months MET/CBT12, ACRA and MDFT were doing better and FSN was doing as well as MET/CBT in terms of costs to society.

  • Results of clinical outcomes, cost-effectiveness, and benefit cost were different – suggesting the importance of multiple perspectives


Impact and next steps l.jpg

Impact and Next Steps

  • 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 under review and 30 month findings being submitted this year.

  • Interventions being replicated as part of over two 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

Source: Dennis et al, 2002, under review


Implications l.jpg

Implications

  • The CYT interventions provide replicable models of 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.


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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.chestnut.org/li/cyt/findings or

www.chestnut.org/li/bookstore

NCADI: www.health.org/govpubs

PETSA: www.samhsa.gov/centers/csat/csat.html

(then select PETS from program resources)


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