Effective Brief Treatments for Adolescents & Transition Age Youth Michael L. Dennis, Ph.D., Chestnut Health Systems, Normal, IL Randolph Muck, M.Ed. Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT), Rockville, MD Presentation at the YouthBuild Learning Exchange, Chicago, IL, May 27, This presentation was supported by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contracts , as well as several individual CSAT, NIAAA, NIDA and private foundation grants. The opinions are those of the authors and do not reflect official positions of the consortium or government. Available on line at or by contacting Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761, phone , fax , Questions about the GAIN can also be sent to Questions about SAMHSA and funding should be directed to Mr. Randolph D. Muck, 1 Choke Cherry Drive, Room , Rockville, MD 20857,

Background In 1997 the third wave of cannabis use was the largest and youngest cohort to date, double the number of adolescents presenting to publicly funded treatment There were no publicly available manual guided evidenced based practices targeting this population The Cannabis Youth Treatment (CYT; Dennis et al 2004) experiments (n=600) were designed to manualize and field test five promising intervention for short term outpatient treatment of adolescent with cannabis (and other) substance use disorders While all five approaches did better than treatment as usual and were similar in their clinical effectiveness, were easier and less expensive to delivery and hence found to be more cost effective: –Motivational Enhancement Therapy/ Cognitive Behavior Therapy for 5 sessions (MET/CBT5; Sample & Kadden 2001) –Adolescent Community Reinforcement approach (ACRA; Godley, Meyers, Smith, Karvinen, Titus, Godley, Dent, Passetti, & Kelberg, 2001)

Moderate to large differences in Cost-Effectiveness by Condition Source: Dennis et al., 2004 $0 $4 $8 $12 $16 $20 Cost per day of abstinence over 12 months $0 $4,000 $8,000 $12,000 $16,000 $20,000 Cost per person in recovery at month 12 CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38 CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 MET/ CBT5 MET/ CBT12 FSN MET/ CBT5 ACRA MDFT * p<.05 effect size f=0.48 ** p<.05, effect size f=0.72 Trial 1 Trial 2 * p<.05 effect size f=0.22 ** p<.05, effect size f=0.78 MET/CBT5 and 12 did better than FSN ACRA did better than MET/CBT5, and both did better than MDFT

Cost Per Person in Recovery at 12 and 30 Months After Intake by CYT Condition Source: Dennis et al., 2003; forthcoming $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 CPPR at 30 months** $6,437 $10,405 $24,725 $27,109 $8,257 $14,222 CPPR at 12 months* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 MET/ CBT5MET/ CBT12FSNMMET/ CBT5ACRAMDFT Trial 1 (n=299)Trial 2 (n=297) Cost Per Person in Recovery (CPPR) * 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 Stability of MET/CBT-5 findings mixed at 30 months MET/CBT-5, -12 and ACRA more cost effective at 12 months Integrated family therapy (MDFT) was more cost effective than adding it on top of treatment (FSN) at 30 months ACRA Effect Largely Sustained

Effective Adolescent Treatment (EAT) From 2003 to 2008 SAMHSA’s Center for Substance Abuse Treatment (CSAT) conducted a phase IV (i.e., post randomization) replication of MET/CBT5 in 36 sites. All sites received standardized training, quality assurance and monitoring on their implementation of MET/CBT5, as well as the collection of data with the Global Appraisal of Individual Needs (GAIN) to facilitate comparison with the original CYT study in terms of implementation and outcome. The objectives of this program were to : 1.Demonstrate that EAT used MET/CBT5 with a more diverse population 2.Replicate the implementation and outcomes of MET/CBT5 3.Identify participant characteristics moderators and intervention mediators that are associated with outcomes

EAT More Geographically Diverse AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY CYT: 4 Sites Included EAT: 24 Sites Excluded EAT: 12 Sites

Demographics Race groups* Age groups* *p<.01 EAT Clients were more likely to be female, non-white, and have a wider age range

Clinical Characteristics Primary Substance Comobidity Delinquency Level* *p<.01 EAT Clients less likely to have cannabis as primary substance, similar in their comorbidity, and to have more justice system involvement.

EAT did as well or Better as CYT on Service Engagement *p<.01

Days of Treatment in the First 3 Months *p<.01 84% 94%

Change in Days Abstinent by Study (f=.02) Slopes are NOT significantly different EAT more severe

Replication and Site Effects – 12 months Treatment can vary by implementation within site/clinic We want to compare the range of implementation in practice with the clinical trials In order to compare sites, we will at both the central tendency (median) and distribution using a Tukey Box Plot like the one shown here. Criteria MedianMiddle 50% “Range”

Range of Effect Sizes (d) for Change in Days of Abstinence (intake to 12 months) by Site CYT Sites (f=0.39) (median within site d=0.29) 36 EAT Sites (f=0.21) (median within site d=0.49) Cohen’s d Source: Dennis, Ives, & Muck, 2008 EAT Programs did Better than CYT on average 75% above CYT median 6 programs completely above CYT

Change in Days Abstinent by Cocaine/Crack Problem Severity at Intake (f=.27)* * P<.0001

Change in Days Abstinent by Any Opioid Use in community at Intake (f=.16)* * P<.0001

Change in Days Abstinent by Age group at intake (f=.05)

Other Client Characteristics that did NOT Predict the Amount of Change Race Single Parent Metropolitan size Primary drug Days of use or problem group for alcohol, cannabis, amphetamine Victimization Psychopathology Delinquency levels

Assertive Adolescent Family Therapy (AAFT) From 2006 to 2013 SAMHSA’s Center for Substance Abuse Treatment (CSAT) is funding a phase IV replication of ACRA plus Assertive Continuing Care (ACC) in 47 sites so far and plans to fund 33 or more later this year. All sites received standardized training, quality assurance and monitoring on their implementation of ACRA and ACC, as well as the collection of data with the GAIN to facilitate comparison with the original CYT study and EAT in terms of implementation and outcome. Goals to replicate the implementation of ACRA/ACC in a broader range of populations/settings and to identify if its effectiveness varies by them in any way.

Assertive Adolescent Family Treatment (AAFT) Grant Sites by Funding Cohort* AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY PR VI Aurora Boston Cambridge Cleveland Columbia Columbus Denver Downey Fitchburg Fresno Ft Worth Houston Huntington Huntsville Jacksonville Knoxville Laredo Little Rock Lk Charles Los Angeles Manchester Miami Mission Nashville New York Oakland Orlando Phoenix Pinellas Park Reno San Antonio San Francisco Seattle Syracuse Tarzana Thornton Tucson 2006 (15) 2007 (16) 2009 (14) *33 or more to be funded in 2010

20 Change in Abstinence (6 mo-Intake) after A- CRA by degree of Implementation Monitoring Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961) (high monitoring)(mod. monitoring) (training only) Effects associated with intensity of quality assurance and monitoring

% Change in GPRA Abstinence Measure ((6 month – intake)/ intake) * GAIN Mandated, ** GAIN Optional Source: SAIS System (GPRA)

Conclusions EAT & AAFT grantees were more diverse geographically, demographically and clinically EAT & AAFT grantees implementation was better than CYT in terms of engagement, similar in dosage, and only slightly less in content Baseline severity was the primary factor explaining differences in the amount of change observed in EAT Engagement, dosage and content were not the major mediator of change – environmental variables were in EAT and overall outcomes were similar or better Both EAT and AAFT are doing better than general CSAT grantees involving and even targeting youth.