Using recovery management checkups for primary care to improve linkage to alcohol and other drug use treatment: a randomized controlled trial three month findings.

BACKGROUND AND AIMS: Recovery management checkups (RMC) have established efficacy for linking patients to substance use disorder (SUD) treatment. This study tested whether using RMC in combination with screening, brief intervention, and referral to treatment (SBIRT), versus SBIRT alone, can improve linkage of primary care patients referred to SUD treatment. DESIGN: A randomized controlled trial of SBIRT as usual (n = 132) versus SBIRT plus recovery management checkups for primary care (RMC-PC) (n = 134) with follow-up assessments at 3 months post-baseline. SETTING: Four federally qualified health centers in the United States serving low-income populations. PARTICIPANTS: Primary care patients (n = 266, 64% male, 80% Black, mean age, 48.3 [range, 19-53]) who were referred to SUD treatment after SBIRT. INTERVENTIONS: SBIRT alone (control condition) compared with SBIRT + RMC-PC (experimental condition). MEASUREMENT: The primary outcome was any days of SUD treatment in the past 3 months. Key secondary outcomes were days of SUD treatment overall and by level of care, days of alcohol and other drug (AOD) abstinence, and days of using specific substances, all based on self-report. FINDINGS: At 3-month follow-up, those assigned to SBIRT + RMC-PC (n = 134) had higher odds of receiving any SUD treatment (46% vs 20%; adjusted odds ratio = 4.50 [2.49, 8.48]) compared with SBIRT only, including higher rates of entering residential and intensive outpatient treatment. They also reported more days of treatment (14.45, vs 7.13; d = +0.26), more days abstinent (41.3 vs 31.9; d = +0.22), and fewer days of using alcohol (27.14, vs 36.31; d = -0.25) and cannabis (19.49, vs 28.6; d = -0.20). CONCLUSIONS: Recovery management checkups in combination with screening, brief intervention, and referral to treatment are an effective strategy for improving linkage of primary care patients in need to substance use disorder treatment over 3 months.

Temporal dynamics of the relationship between change in depressive symptoms and cannabis use in adolescents receiving psychosocial treatment for cannabis use disorder.

AIMS: Cannabis use disorder (CUD) and depression frequently co-occur in youth. How depressive symptoms change over the course of CUD treatment and how they impact substance use treatment outcomes is unknown. In the current study, we examine the temporal relationships between cannabis use and depression in adolescents receiving evidence-based treatments for CUD as part of a multisite clinical trial. DESIGN: Six hundred adolescents (age 12-18) with a CUD were randomly assigned to substance use treatment from one of five evidence-based psychosocial interventions. We assessed self-reported cannabis use frequency and depressive symptoms at baseline (BL) and again at 3-, 6-, 9, and 12-months. A bivariate latent change model assessed bidirectional effects of baseline levels and time-lagged changes in depressive symptoms and cannabis use on depression and cannabis use outcomes. FINDINGS: Depressive symptoms (72%) and major depressive disorder (MDD) (18%) were common at BL. Both depression and cannabis use decreased over time and change in cannabis use was significantly associated with change in depressive symptoms (b = 1.22, p = .003). Time-lag analyses showed that within-subject change in depression (from one time point to the next) was predicted by previous depression (b = -0.71, p < .001) but not cannabis use (p = .068), and change (decrease) in cannabis use was predicted by previous (greater) depressive symptoms (b = -1.47, p < .001) but not cannabis use (p = .158), respectively. CONCLUSION: These findings indicate an enduring relationship between decreasing cannabis use and decreasing depression among adolescents lasting for 9-months after receiving psychosocial interventions for CUD. The presence of depressive symptoms did not appear to interfere with substance use treatment or attenuate improvements in cannabis use frequency. A decrease in cannabis use was not contingent upon a reduction in depressive symptoms. These findings are limited by the possibility of regression to the mean for both cannabis use and depressive symptoms, and the lack of a nonintervention control group.

The added risk of opioid problem use among treatment-seeking youth with marijuana and/or alcohol problem use.

OBJECTIVES: To determine the added risk of opioid problem use (OPU) in youth with marijuana/alcohol problem use (MAPU). METHODS: A total of 475 youth (ages 14-21 years) with OPU + MAPU were compared to a weighted sample of 475 youth with MAPU only (i.e. no OPU) before and after propensity score matching on gender, age, race, level of care and weekly use of marijuana/alcohol. Youth were recruited from 88 drug treatment sites participating in eight Center for Substance Abuse Treatment-funded grants. At treatment intake, participants were administered the Global Appraisal of Individual Need to elicit information on demographic, social, substance, mental health, human immunodeficiency virus (HIV), physical and legal characteristics. Odds ratios with confidence intervals were calculated. RESULTS: The added risk of OPU among MAPU youth was associated with greater comorbidity; higher rates of psychiatric symptoms and trauma/victimization; greater needle use and sex-related HIV risk behaviours; and greater physical distress. The OPU + MAPU group was less likely to be African American or other race and more likely to be aged 15-17 years, Caucasian; report weekly drug use at home and among peers; engage in illegal behaviors and be confined longer; have greater substance abuse severity and polydrug use; and use mental health and substance abuse treatment services. CONCLUSIONS: These findings expand upon the existing literature and highlight the substantial incremental risk of OPU on multiple comorbid areas among treatment-seeking youth. Further evaluation is needed to assess their outcomes following standard drug treatment and to evaluate specialized interventions for this subgroup of severely impaired youth.

The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders.

AIMS: This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1-3) and longer-term (months 4-9) abstinence. DESIGN: Two-group randomized design. SETTING: Eleven counties surrounding a community-based residential treatment program in the Midwestern section of the United States. PARTICIPANTS: A total of 183 adolescents, ages 12-17 years, with one or more Diagnostic and Statistical Manual version IV (DSM-IV) substance use dependence disorder and met American Society for Addiction Medicine (ASAM) placement criteria for non-medical residential treatment. INTERVENTION: Prior to discharge from residential treatment, participants were assigned randomly to receive either UCC, available at outpatient clinics in the 11-county study area, or ACC via home visits. MEASUREMENTS: Self-reported interview data were collected at intake, 3, 6 and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months. FINDINGS: ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence. CONCLUSIONS: ACC appears to be an effective alternative to UCC for linking, retaining and increasing adherence to continuing care. Replication with larger samples is needed to investigate further the direct and indirect effects of ACC found in this study

Absence of iatrogenic or contagion effects in adolescent group therapy: findings from the Cannabis Youth Treatment (CYT) study.

Though widely used and presumed effective in practice, some scholars (Dishion et al., 1999) have raised the concern that group therapy for adolescents with substance use disorder and a range of deviancy has the potential for causing iatrogenic effects (e.g., increased substance use, behavior and legal problems) for those with low deviancy. Using data from 400 youth in the largest adolescent treatment experiment conducted to date (Dennis et al., 2004), this study shows that group composition in terms of conduct disorder symptoms is not associated with worse substance use, psychological, environmental or legal treatment outcomes. The results actually indicated that there was a slight advantage for youth with high conduct disorder to be included in the groups with less symptoms. The results appear consistent with recent meta-analyses of delinquency studies (Lipsey, 2006) which have found no evidence of iatrogenic effects. These results support the common clinical belief that group therapy for youths with substance use disorders is a safe and effective treatment modality.

Early therapeutic alliance as a predictor of treatment outcome for adolescent cannabis users in outpatient treatment.

The association of early alliance to treatment attendance and longitudinal outcomes were examined in 356 adolescents participating in a randomized clinical trial targeting cannabis use. Both patient and therapist views of alliance were examined, and outcomes were evaluated over 12 months after numerous other sources of variance were controlled. Patient-rated alliance predicted a reduction in cannabis use at three and six months and a reduction in substance-related problem behaviors at six months. Therapist-rated alliance did not predict outcomes. Neither patient nor therapist alliance ratings were associated with attendance. The findings support the important and often overlooked role that alliance can play in treating substance abusing, often delinquent, adolescents.

The construct and predictive validity of different approaches to combining urine and self-reported drug use measures among older adolescents after substance abuse treatment.

Reconciling urine results and self-reports is a classic challenge in substance abuse treatment research in general. For adolescents, the problems are compounded by the facts that they are more likely to use marijuana (which takes longer to metabolize) and to be coerced into treatment (which may increase lying). This article examines the construct and predictive validity of several different approaches for combining urine and self reported drug use including using common individual measures (urine tests and self-reported recency, frequency, and peak use), taking either as positive, using a summary scale, and using a latent model. Data are from 819 older adolescents 24 to 42 months after intake in seven sites. Days of use, the GAIN's substance frequency scale, and a latent model were the three best methods in terms of construct and predictive validity. Implications for treatment and longitudinal evaluation will be discussed.

The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment for cannabis abuse or dependence.

Because alcohol or other drug use following adolescent substance abuse treatment is common, understanding mediators of posttreatment outcome could help improve treatment interventions. The authors conducted path analyses based on data from 552 adolescents (aged 12-18; 82% male) with cannabis abuse or dependence who participated in outpatient treatment. The analysis used the Family Conflict and Cohesion subscales, from the Family Environment Scale, and several scales and indices from the Global Appraisal of Individual Needs. Family conflict, family cohesion, and social support indirectly predicted substance use and substance-related problems as mediated by recovery environment and social risk. This model replicated across 4 follow-up waves (3, 6, 9, and 12 months postintake). These results support the idea of targeting environmental factors during continuing care as a way to improve treatment outcomes for adolescents with cannabis disorders.

The duration and correlates of addiction and treatment careers.

While addiction is increasingly recognized as a chronic condition, little information is available on the actual duration of addiction and treatment careers. The purpose of this study was to estimate the duration and correlates of years between (a) first use and at least a year of abstinence and (b) first treatment admission and at least one year of abstinence. Data are from 1,271 of 1,326 (96%) people recruited from a stratified sequential sample of admissions to publicly funded treatment programs in a large metropolitan area. Participants were interviewed at 6, 18, 24, 36, 48, and 60 months post-intake. With an average age at the referent intake of 35 (SD = 8) years, the sample is 59% female, 87% African American, 7% Hispanic, and 5% white. The most common dependence diagnoses were for cocaine (64%), alcohol (44%), opioids (41%), and/or marijuana (14%). Using lifetime substance use and treatment histories collected at intake and subsequent treatment utilization recorded during follow-up interviews, we conducted survival analysis to estimate the time from first use and first treatment until people reported 12 months of abstinence or died (with people still using, in treatment, or dead at the last follow-up treated as right censored). During the three years after intake, 47% reached at least 12 months of abstinence. The median time from first to last use was 27 years. The median time from first treatment episode to last use was 9 years. Years to recovery were significantly longer for males, people starting use under the age of 21 (particularly those starting under the age of 15), people who had participated in treatment 3 or more times, and for people high in mental distress. The exploratory results suggest that multiple episodes of care over several years are the norm and that rather than thinking of multiple episodes in terms of "cumulative dosage," it might be better thought of as further evidence of chronicity and that we need to develop and evaluate models of longer term recovery management.

Cross-validation of the alcohol and cannabis use measures in the Global Appraisal of Individual Needs (GAIN) and Timeline Followback (TLFB; Form 90) among adolescents in substance abuse treatment.

AIMS: To examine the comparability, reliability and predictive validity of two instruments used to assess alcohol use and dependence: the Global Appraisal of Individual Needs (GAIN) and the Form 90 Timeline Followback (TLFB) method. DESIGN, SETTING AND PARTICIPANTS: Adolescents (n = 101) admitted to a residential treatment program in the United States were interviewed at intake with the GAIN, and again within a week with a variation of TLFB, called Form 90. Alcohol and cannabis measures were compared and used to predict the number of past-month substance abuse and dependence symptoms. MEASUREMENT: Self-report measures of days of alcohol and cannabis use in the 90 days prior to intake, peak number of drinks/joints used, peak blood alcohol content (BAC) and alcohol and cannabis abuse and dependence symptom counts. FINDINGS: Results revealed that the measures had: (a) excellent comparability (r = 0.7-0.8) across the two instruments; (b) deteriorating reliability after reported peak BAC levels exceeded 0.50 and peak joints exceeding 19; and (c) similar and strong relationships between use measures and the number of abuse/dependence symptoms across measures and instruments. CONCLUSIONS: In a sample of 101 adolescents who were admitted to residential treatment for alcohol or drug dependence, the corresponding measures from the two instruments produced comparable results. If the cross-validation of these two measures generalizes to adolescents treated in out-patient settings and other adolescent treatment populations, the GAIN and Form 90 may provide useful core alcohol measures for meta-analyses.

Thirty-month relapse trajectory cluster groups among adolescents discharged from out-patient treatment.

AIMS: To identify adolescent relapse trajectory groups following discharge from out-patient substance abuse treatment. DESIGN, SETTING AND PARTICIPANTS: Adolescents aged 12-18, who were assigned randomly to one of five out-patient interventions (n = 563) in four United States communities and followed-up 3, 6, 9, 12 and 30 months post-intake. OUTCOME MEASURES: Self-report measures of days using any alcohol or other drugs (AOD), days of alcohol use, days of cannabis use, days of heavy use, days of crack/cocaine use, days of heroin/opiate use, days AOD use interfered with responsibilities and days in a controlled environment. FINDINGS: Adolescents can be grouped empirically into five relapse trajectories over 30 months following out-patient treatment: (a) low AOD use with limited days in a controlled environment; (b) low AOD use with high days in a controlled environment; (c) moderate/decreasing AOD use; (d) increasing AOD use; and (e) consistently high AOD use. CONCLUSIONS: There was considerable heterogeneity in the relapse trajectories, varying by the initial response to treatment, the stability (versus increase/decrease) of the response and an interaction with time in a controlled environment. Cannabis and alcohol were the two main substances involved, although the two groups with the poorest trajectories had increasing levels of cocaine, opiate and other substance use at the 30-month follow-up. This study demonstrates the chronicity of substance use even among a subgroup of adolescents and the importance of studying more complex longitudinal patterns of recovery.

Outpatient marijuana treatment for adolescents. Economic evaluation of a multisite field experiment.

An economic evaluation of five outpatient adolescent treatment approaches (12 total site-by-conditions) was conducted. The economic cost of each of the 12 site-specific treatment conditions was determined by the Drug Abuse Treatment Cost Analysis Program (DATCAP). Economic benefits of treatment were estimated by first monetizing a series of treatment outcomes and then analyzing the magnitude of these monetized outcomes from baseline through the 12-month follow-up. The average economic costs ranged from $90 to $313 per week and from $839 to $3,279 per episode. Relative to the quarter before intake, the average quarterly cost to society for the next 12 months (including treatment costs) significantly declined in 4 of the 12 site-by-treatment conditions, remained unchanged in 6 conditions, and increased in 2 treatment conditions (both in the same site). These results suggest that some types of substance-abuse intervention for adolescents can reduce social costs immediately after treatment.

Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment.

AIMS: Risk factors among adolescent substance abusers have been shown to correlate with substance use severity. Characteristics related to severity, such as demographic and family factors, peer influences, psychiatric co-morbidity and HIV risk behaviors, are examined for a sample of adolescent cannabis users entering treatment. DESIGN: These data are from a clinical trial study utilizing blocked random assignment of clients to one of five treatment conditions. The study targeted adolescents entering outpatient treatment for primarily cannabis abuse or dependence. SETTING: Treatment and research facilities in four metropolitan areas of the US were used to recruit study participants. Treatment was delivered in outpatient drug-free settings. PARTICIPANTS: Participants were 600 clients, ages 12-18, admitted to outpatient substance abuse treatment programs for cannabis problems, 96% with DSM-IV diagnoses of substance abuse or dependence, with the remaining 4% having at least one symptom of dependence plus significant problems indicating need for treatment. MEASUREMENTS: The Global Appraisal of Individual Needs (GAIN) was used to collect the information presented in this paper. The GAIN incorporates DSM-IV criteria for substance use disorders, conduct disorder and attention deficit hyperactivity disorder, as well as dimensional (scale) measures for physical and mental health. FINDINGS: All participants reported at least one symptom of substance use disorders, and 46% met the DSM-IV criteria for substance dependence, while 50% met criteria for a diagnosis of abuse. Only 20% of the participants perceived any need for help with problems associated with their drug or alcohol use. Clients participating in the study typically presented multiple problems at treatment entry, most often including conduct disorder, attention deficit hyperactivity disorder (ADHD), internal (mental) distress, and physical health distress. The co-occurrence of conduct disorder and ADHD was found in 30% of the sample. Clients meeting criteria for substance dependence tended to have more co-occurring problems and significantly less denial at admission. CONCLUSIONS: The characteristics of this sample exemplify the complex nature of adolescent substance use and abuse among adolescents entering outpatient treatment programs. Patterns of co-occurring problems are at rates comparable to those found in other clinical studies. Those with more severe substance use disorders tend to manifest more problems of social functioning, more mental health problems, and physical health problems. Implications of these findings are discussed in terms of treatment needs, challenges, and prognostic implications.

The economic cost of outpatient marijuana treatment for adolescents: findings from a multi-site field experiment.

AIMS: Despite recent advances in the economic evaluation of adult substance abuse treatment, information and basic research is lacking on the cost of adolescent substance abuse treatment. The present study conducted an economic cost analysis of several outpatient adolescent treatment approaches. DESIGN: The Cannabis Youth Treatment (CYT) study evaluated five structured treatments for cannabis-using adolescents. One of the approaches was implemented by all of the four geographically and institutionally diverse treatment facilities collaborating in CYT; each of the other four approaches was implemented in two of the sites. Using the Drug Abuse Treatment Cost Analysis Program (DATCAP), the economic cost of each site-specific treatment was determined. FINDINGS: The average economic costs of the five types of outpatient treatments ranged from $837 to $3334 per episode, and varied by both direct factors (e.g. hours of treatment, treatment retention) and indirect factors (e.g. cost of living, staff level, case-load variation). CONCLUSIONS: These adolescent treatment cost estimates are examined in terms of their calculation, variability by condition, variability by site within condition and comparability with previous DATCAP results from outpatient drug-free programs for adults. Future research will integrate treatment outcomes and costs to complete cost-effectiveness and benefit-cost analyses of the five therapies.

Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment.

In many treatment systems, adolescents referred to residential treatment have the most serious alcohol or other substance use disorders and are at high risk of relapse. Upon discharge, these adolescents are typically referred to continuing care services, however, linkage to these services is often problematic. In this study, 114 adolescents (76% male) who stayed at least 7 days in residential treatment were randomly assigned to receive either usual continuing care (UCC) or UCC plus an assertive continuing care protocol (ACC) involving case management and the adolescent community reinforcement approach. ACC participants were significantly more likely to initiate and receive more continuing care services, to be abstinent from marijuana at 3 months postdischarge, and to reduce their 3-month postdischarge days of alcohol use. Preliminary findings demonstrate an ACC approach designed for adolescents can increase linkage and retention in continuing care and improve short-term substance use outcomes.