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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 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.

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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

objectives
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.
the adolescent marijuana problem circa 1997 1998
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
the state of adolescent treatment circa 1997 1998
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
purpose of cyt
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
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)
two trials or study arms
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

actual treatment received by condition
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

average episode cost us of treatment

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

implementation of evaluation
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

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Adolescent Cannabis Users in CYT were

as or More Severe Than Those in TEDS*

Source: Tims et al, 2002

slide14

Demographic Characteristics

Source: Tims et al, 2002

slide15

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

slide17

Multiple Problems are the NORM

Self-Reported in Past Year

Source: Dennis et al, under review

slide18

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

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

slide19

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

Source: Dennis et al., in press

slide20

Similarity of Clinical Outcomes

by Conditions

Source: Dennis et al., in press.

slide21

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

evaluating the long term effects of treatment

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

cumulative recovery pattern at 30 months the majority vacillate in and out of recovery
Cumulative Recovery Pattern at 30 months:(The Majority Vacillate in and out of Recovery)

Source: Dennis et al, forthcoming

slide24

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

slide25

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

dissemination and impact
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
cyt was part of a renascence of adolescent treatment research practice
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.

slide30

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

conclusions
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
contact information
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: [email protected]

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)

cyt related references
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.

cyt related references continued
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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