Michael Dennis, Ph.D. Chestnut Health Systems, Normal, IL October 28, 2009

1. Intervening with Adolescent Substance User:What do we know so far about and where do we go from here Michael Dennis, Ph.D. Chestnut Health Systems, Normal, IL October 28, 2009 Presentation for the Student Assistance Prevention and Intervention Services Program (SAPISP) providers at the Puget Sound Educational School District, Renton, WA, October 27-30, 2009. This presentation was supported by PSESD, ESD113, and King County. The author would like to thank Dennis Deck for providing the tables of 2009 SAPISP data. The presentation also reports on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contracts 270-2003-00006 and 270-07-0191, as well as several individual CSAT, NIAAA, NIDA and private foundation grants. The opinions are those of the author and do not reflect official positions of the consortium or 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

2. Goals of this workshop are to • Describe the prevalence, course, and consequences of adolescent substance use and recovery • Summarize the Move Towards Screening, Brief Intervention, and Referral to (Long Term) Treatment • DiscussTrends in the Adolescent Substance Abuse Treatment System in the United States (US) • Highlight what it takes to move the field towards evidenced-based practice related to assessment, treatment, program evaluation and planning • Provide an overview of the GAIN Short Screener and Results from the Student Assistance Prevention and Intervention Services Program (SAPISP) in Washington State • Stimulate a discussion of the implications for further program planning and evaluation

3. Part 1. Prevalence, course, and consequences of adolescent substance use and recovery

4. Severity of Past Year Substance Use/Disorders(2002 U.S. Household Population age 12+= 235,143,246) Dependence 5% Abuse 4% No Alcohol or Regular AOD Drug Use 32% Use 8% Any Infrequent Drug Use 4% Light Alcohol Use Only 47% Source: 2002 NSDUH, Dennis & Scott 2007

5. Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Problems Vary by Age NSDUH Age Groups 100 People with drug dependence die an average of 22.5 years sooner than those without a diagnosis 90 80 70 60 Severity Category 50 No Alcohol or Drug Use Light Alcohol Use Only 40 Any Infrequent Drug Use 30 Regular AOD Use 20 Abuse 10 Dependence 0 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Source: 2002 NSDUH and Dennis & Scott 2007

6. Substance use severity is related to crime and violence Crime & Violence by Substance Severity Adolescents 12-17 Source: NSDUH 2006

7. ..as well as family, school and mental health problems Family, Vocational & MH by Substance Severity Adolescents 12-17 Source: NSDUH 2006

8. Brain Activity on PET Scan After Using Cocaine Rapid rise in brain activity after taking cocaine Actually ends up lower than they started Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377.

9. Prolonged Substance Use Injures The Brain: Healing Takes Time Normal levels of brain activity in PET scans show up in yellow to red Normal Reduced brain activity after regular use can be seen even after 10 days of abstinence 10 days of abstinence After 100 days of abstinence, we can see brain activity “starting” to recover 100 days of abstinence Source: Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.

10. Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

11. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.

12. People Entering Publicly Funded Treatment Generally Use For Decades It takes 27 years before half reach 1 or more years of abstinence or die 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent still using Years from first use to 1+ years of abstinence 0 5 10 15 20 25 30 Source: Dennis et al., 2005

13. The Younger They Start, The Longer They Use 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent still using Age of First Use* Years from first use to 1+ years of abstinence under 15 60% longer 15-20 21+ 0 5 10 15 20 25 30 * p<.05 Source: Dennis et al., 2005

14. The Sooner They Get The Treatment, The Quicker They Get To Abstinence 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Years to first Treatment Admission* Percent still using 20 or more years Years from first use to 1+ years of abstinence 57% quicker 10 to 19 years 0 to 9 years 0 5 10 15 20 25 30 • p<.05 Source: Dennis et al., 2005

15. After Initial Treatment… • Relapse is common, particularly for those who: • Are Younger • Have already been to treatment multiple times • Have more mental health issues or pain • It takes an average of 3 to 4 treatment admissions over 9 years before half reach a year of abstinence • Yet over 2/3rds do eventually abstain • Treatment predicts who starts abstinence • Self help engagement predicts who stays abstinent Source: Dennis et al., 2005, Scott et al 2005

16. 86% 66% 36% After 4 years of abstinence, about 86% will make it another year The Likelihood of Sustaining Abstinence Another Year Grows Over Time After 1 to 3 years of abstinence, 2/3rds will make it another year 100% . Only a third of people with 1 to 12 months of abstinence will sustain it another year 90% 80% 70% 60% % Sustaining Abstinence Another Year 50% 40% 30% 20% 10% 0% 1 to 12 months 1 to 3 years 4 to 7 years But even after 7 years of abstinence, about 14% relapse each year Duration of Abstinence Source: Dennis, Foss & Scott (2007)

17. What does recovery look like on average? Duration of Abstinence 1-12 Months 1-3 Years 4-7 Years • More clean and sober friends • Less illegal activity and • incarceration • Less homelessness, violence and • victimization • Less use by others at home, work, • and by social peers • Virtual elimination of illegal activity and illegal • income • Better housing and living situations • Increasing employment and income • More social and spiritual support • Better mental health • Housing and living situations continue to improve • Dramatic rise in employment and income • Dramatic drop in people living below the poverty line Source: Dennis, Foss & Scott (2007)

18. The Risk of Death goes down with years of sustained abstinence Sustained Abstinence Also ReducesThe Risk of Death Users/Early Abstainers more likely to die in the next 12 months It takes 4 or more years of abstinence for risk to get down to community levels Deaths in the next 12 months - (Matched on Gender, Race & Age) Source: Scott, Dennis, Simeone & Funk (forthcoming)

19. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents More likely than adults to be diverted to treatment (OR=4.0) 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 More likely than adults to stay 90 days in treatment (OR=1.7) 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

20. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: 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.

21. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: 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

22. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents • 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

23. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents Probability of Going to Using vs. Early “Recovery” (+ good) + Recovery Environment (r)* (3.33) 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

24. Cumulative Recovery Pattern at 30 months 5% Sustained Recovery 37% Sustained 19% Intermittent, Problems currently in recovery 39% Intermittent, currently not in recovery The Majority of Adolescents Cycle in and out of Recovery Source: Dennis et al, forthcoming

25. Recovery* by Level of Care 100% Outpatient (+79%, -1%) 90% Residential(+143%, +17%) 80% Post Corr/Res (+220%, +18%) 70% CC better 60% Percent in Past Month Recovery* 50% OP & Resid Similar 40% 30% 20% 10% 0% Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12 * Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT Adolescent Treatment Outcome Data Set (n-9,276)

26. Early Re-Intervention Experiment 2 (ERI2) • Recruitment of 448 adults from Community Based Treatment in Chicago in 2000 (84% of eligible recruited) • Quarterly follow-up for 4 years (95-97% follow-up) • Random assignment to Outcome Monitoring (OM) Control quarterly interviewing Control) or Recovery Management Checkups (RMC) Experiment • Measures include the GAIN, CEST, CAI, NEO, CRI, urine tests, and staff logs • Proximal Outcomes: Reduced time readmission, increased treatment, reduce successive quarters using in community • Distal Outcomes: Reduced substance use, emotional problems and HIV risk behaviors

27. Sample Characteristics of ERI-2 Experiment 100% 20% 40% 60% 80% 0% African American Age 30-49 Female Current CJ Involved Past Year Dependence Prior Treatment Residential Treatment Other Mental Disorders Homeless ERI 2 (n=446) Physical Health Problems * No significant differences by condition

28. Recovery Management Checkup (RMC) • Quarterly Screening to determining “Eligibility” and “Need” • Linkage meeting/motivational interviewing to: • provide personalized feedback to participants about their substance use and related problems, • help the participant recognize the problem and consider returning to treatment, • address existing barriers to treatment, and • schedule an assessment. • Linkage assistance • reminder calls and rescheduling • Transportation and being escorted as needed • Treatment Engagement Specialist

29. Less Risk Behaviors, MH and Crime Less Successive Quarters Using Reduce Time to Re-admission Relative to Control, RMC will reduce the time from relapse to readmission The quicker the return to treatment, the less successive quarters using in the community The less quarters using in the community, the less HIV Risk Behaviors, Mental Health and Crime Problems Early Re-Intervention (ERI) Experiment and Hypotheses Monitoring and Early Re-Intervention Source: Dennis et al 2003, 2007; Scott et al 2005, 2009

30. The size of the effect is growing every quarter 45-13 = -32 months (d=-.41) ERI-2 Time to Treatment Re-Entry at Year 4 RMC increases the odds of re-entering treatment over 4 years by 3.1 100% 90% 80% (n=198) 74% ERI-2 RMC* 70% Percent Readmitted 1+ Times 60% 48% ERI-2 OM (n=195) 50% 40% 30% 20% 10% 0% Wilcoxon-Gehen statistic (df=1) = 28.60, p<.001 OR=3.1, p<.05 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 Months from 1st Follow-up In Need for Treatment , Source: Dennis & Scott, 2009

31. More days of abstinent RMC Increased Treatment Participation RMC Increased Treatment Participation Less likely to be in Need at 45m Fewer Seq. Quarters in Need 74% 71% 61% 47% 38% ERI-2: Impact on Outcomes at 45 Months OM RMC 100% 90% 80% 70% 67% 56% 60% 55% 50% Percentage 50% 41% 40% 30% 20% 10% 0% of 180 Days of 14 Subsequent Re-entered of 1260 Days Still in need of Tx at Mon 45 of Treatment Quarters in Need Treatment Abstinent (d=0.22)* (d= 0.26) * (d= 0.26)* (d= -0.32)* (d= -0.22) * * p<.05 Source: Scott & Dennis (2009)

32. Positive Consequences of Early Readmission • Checkups and Early Readmission to Treatment were associated with: • Less substance use and problems • Longer periods of abstinence • More attendance and engagement in self help activities • Above were associated with: • Fewer HIV risk behaviours • Less illegal activity, arrests, and time incarcerated • Fewer mental health problems • Less utilization and costs to society Source: Dennis & Scott (2009)

33. Cost of Substance Abuse Treatment Episode • $750 per night in Detox • $1,115 per night in hospital • $13,000 per week in intensive • care for premature baby • $27,000 per robbery • $67,000 per assault $70,000/year to keep a child in detention $22,000 / year to incarcerate an adult $30,000/ child-year in foster care Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004

34. Investing in Treatment has a Positive Annual Return on Investment (ROI) • Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested • Treatment drug courts have an average ROI of $2.14 to $2.71 per dollar invested This also means that for every dollar treatment is cut, we lose more money than we saved. Source: Bhati et al., (2008); Ettner et al., (2006)

35. Part 2. No Wrong Door: the Move Towards Screening, Brief Intervention, and Referral to (Long Term) Treatment

36. Few Get Treatment: 1 in 17 adolescents, 1 in 22 young adults, 1 in 12 adults Substance Use Disorders are Common,But Treatment Participation Rates Are Low:United States (US) Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Much of the private funding is limited to 30 days or less and authorized day by day or week by week Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

37. Substance Use Disorders are Common,But Treatment Participation Rates Are Low:Washington State Higher problem rate for young adults, but higher treatment rate : 1 in 7 Similar rates for adolescents : 1 in 18 Higher problems rate, and less treatment participation for adults: 1 in 19 Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

38. Substance Use Disorders are Common,But Treatment Participation Rates Are Low:Seattle & King County, WA High higher problems rate, but similar treatment rates: 1 in 19 young adults 1 in 12 adults Similar problem rate but much lower Treatment Rate: 1 in 40 adolescents Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

39. The Movement to Increase Screening • Screening, Brief Intervention and Referral to Treatment (SBIRT) has been shown to be effective in identifying people not currently in treatment, initiating treatment/change and improving outcomes (see http://sbirt.samhsa.gov/ ) • The US Preventive Services Task Force (USPSTF, 2004; 2007), National Quality Forum (NQF, 2007), and Healthy People 2010 have each recommended • regular screening, brief intervention, and referral to treatment (SBIRT) for tobacco and alcohol abuse in general medical settings for everyone • SBIRT for drug use in high risk populations (e.g., adolescents, pregnant and post partum women, people with HIV, and people with co-occurring psychiatric conditions) • CSAT and NIDA are both funding several demonstration and research projects to develop and evaluate models for doing this • Washington State mandated screening in all adolescent and adult substance abuse treatment, mental health, justice, and child welfare programs

40. Adolescent Rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in Washington State Problems could be easily identified Comorbidity is common Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

41. Adult Rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in Washington State Lower than expected rates of SA in Mental Health & Children’s Admin Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

42. Adolescent Client Validation of Hi Co-occurring from GAIN Short Screener vs Clinical Records by Setting in Washington State Two page measure closely approximated all found in the clinical record after the next two years Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

43. Higher rate in clinical record in Mental Health and Children’s Administration. But that was based on • “any use” vs. “week use + abuse/dependence” • - and 2 years vs. past year Adult Client Validation of Hi Co-occurring from GAIN Short Screener vs Clinical Records by Setting in Washington State Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

44. Several Recent Reviews, Experiments and Quasi-Experiments Have Demonstrated That Screening, brief intervention and referral to treatment are being found effective and cost effective More assertive continuing care can increase adherence with continuing care expectations Recovery management checkups can identify people who have relapsed and get them back to treatment faster That doing each improves short and long term outcomes That the rate of improve effects went up as interventions when from less than 3 months (38%) to 3 to 12 months (44%) to more than 12 months (100%) Source: Bhati et al 2008; Dennis et al 2003, 2007, Godley et al 2002, 2007; Marlowe, 2008; McKay, in press; National Quality Forum, 2007; Scott et al 2005, in press; USPSTF, 2004; 2007,

45. Part 3. Trends in the Adolescent Substance Abuse Treatment System in the United States (US)

46. Trends in Adolescent (Age 12-17) Treatment Admissions in the U.S.: 1992-2006 17% drop off from 161,424 in 2002 to 133,723 in 2007 62% increase from 98,952 in 1992 to 161,424 in 2002 Source: Office of Applied Studies 1992- 2007 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

47. Change in Adolescent Admissions by Level of Care in US Public Treatment 1992-2007 Outpatient the most common modality Outpatient the most common modality Source: Office of Applied Studies 1992- 2007 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

48. Change in Adolescent Referral Source in US Public Treatment 1992-2007 Juvenile Justice is the largest source of referral Source: Office of Applied Studies 1992- 2007 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

49. Change in Adolescent Prior Tx Admissions in US Public Treatment 1992-2007 27% of Adolescents have been in treatment before Source: Office of Applied Studies 1992- 2007 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

50. Change in Adolescent Focal Problems in US Public Treatment 1992-2007 But rapid growth in Methampethamine, Opioids and Psychotropic's (exceeds 1000% in several states) Primarily Marijuana and Alcohol Source: Office of Applied Studies 1992- 2007 Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm