Treatment for Adolescent Substance Use Disorders: What Works?

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1 Treatment for Adolescent Substance Use Disorders: What Works? Mark W. Lipsey Emily E. Tanner-Smith Sandra J. Wilson Peabody Research Institute, Vanderbilt University Addiction Health Services Research Meeting -- George Mason University October, 2011

2 Acknowledgements This study was supported by funding from the Center for Substance Abuse Treatment (CSAT) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Opinions expressed in this report are those of the authors and do not necessarily reflect the opinions or policies of CSAT, NIAAA, their staff, or employees. Valuable assistance was provided by Chestnut Health Systems and Michael Dennis.

3 Questions that Motivated this Project What does the available research tell us about the effectiveness of different outpatient treatments for adolescents with substance use disorders? Are there specific characteristics of the adolescent participants and the treatments that are related to the magnitude of treatment effects on substance use outcomes? How do the substance use outcomes reported in research studies compare with those from everyday treatment programs?

4 The Meta-Analysis Analysis of the findings of research studies on the effects of adolescent substance abuse treatment: Outpatient programs for youth age exhibiting clinical levels of abuse or dependence on alcohol, marijuana, or other substances (excluding tobacco and caffeine) Controlled studies (randomized experiments or strong quasi-experiments) that measured substance use outcomes Published in English between 1980 and 2008 Analysis of aggregate data from the GAIN interview reported to Chestnut Health Systems by treatment providers

5 The Research Studies 48 experimental or quasi-experimental studies that reported 77 comparisons of treatment conditions Treatment conditions compared on 256 substance use outcome measures (effect sizes) 40% alcohol [n=103] 16% marijuana/cannabis [n=41] 33% mixed substances [n=84] 11% other specific substances (e.g., cocaine) [n=28]

6 Study Characteristics Study Characteristic Mean Minimum Maximum Publication year Conducted in U.S. 97% Journal publication 68% Randomized control trial 82% Pre post interval (weeks)

7 Participant & General Treatment Characteristics Participant Characteristic Mean Minimum Maximum Proportion of males in sample 72% 0 90 Proportion of Whites in sample 59% Average age (years) Clinically comorbid participants (yes/no) 58% Delinquency level (1 to 5 scale) Treatment Characteristic Some arrested none Treatment duration (weeks) Frequency of treatment contact 1 2/wk once daily all

8 Treatment Conditions Family therapy (k=24, n=84) Multidimensional Family Therapy (k=7, n=20) Functional Family Therapy (k=3, n=11) Multisystemic Therapy (k=5, n=26) Family Support Network (k=2, n=4) Generic family therapy programs (k=7, n=23) Individual counseling (k=5, n=26) Generic counseling programs Mixed counseling (k=6, n=12) Chestnut Health Systems outpatient (k=4, n=4) 7 Challenges (k=1, n=2) Generic mixed counseling (k=1, n=6) k = number of treatment-comparison combinations; n = number of effect sizes.

9 Treatment Conditions (continued) Cognitive behavioral therapy (CBT) (k=13, n=39) Generic CBT programs Motivational interviewing/enhancement therapy (MET) (k=16, n=62) Motivational enhancement therapy (k=10, n=36) Motivational interviewing (k=6, n=26) MET + CBT (MET/CBT) (k=12, n=23) MET/CBT-12 (k=1, n=2) MET/CBT-7 (k=5, n=5) MET/CBT-5 (k=3, n=6) Generic MET/CBT (k=3, n=10) k = number of treatment-comparison combinations; n = number of effect sizes.

10 Treatment Conditions (continued) Behavioral therapy (k=4, n=11) ACRA (k=3, n=10) Generic behavioral (k=1, n=1) Psychoeducational therapy (PET) (k=19, n=55) Generic psychoeducational curriculum (k=7, n=17) Other generic educational programs (k=12, n=38) Skills training (k=6, n=10) Social, anger management, interpersonal skills Pharmacological therapy (k=7, n=13) Seven drugs, one study each k = number of treatment-comparison combinations; n = number of effect sizes.

11 Treatment Conditions (continued) Other treatments (k=7, n=37) Miscellaneous treatment modalities appearing in too few studies to analyze separately Practice as usual (k=9, n=41) Standard practice, e.g., general community treatment, case management No treatment (k=14, n=71) No treatment, assessment only, and delayed treatment control groups k = number of treatment-comparison combinations; n = number of effect sizes.

12 Complications Comparing Treatment Effectiveness Only a few treatment conditions are compared with no treatment controls; studies mostly compare one treatment with another treatment, so get only relative effects. Response: Examine all comparisons and identify the treatments that most often outperform their comparison treatments.

13 Complications Comparing Treatment Effectiveness Different studies use different participant samples are different outcomes because one treatment is more effective or because the adolescents in those studies are more responsive? Response: Use statistical controls for sample characteristics to estimate effects for similar samples across studies. Different studies use different substance use outcome measures are different outcomes because one treatment is more effective or because that study used more sensitive outcome measures? Response: Include all substance use outcome measures but analyze them with statistical controls for the different substances and their measurement characteristics.

14 N of Studies for Each Comparison of Treatment Conditions Fam Ind C Mix C CBT MET MET/C BT Behav PET Skills Pharm Other PAU No Tx Family Indiv Cons Mixed Cons CBT MET MET/CBT Behavioral PET Skills Trng Pharm 7 Other Prac Usual No Tx

15 N of Studies for Each Comparison of Treatment Conditions Fam Ind C Mix C CBT MET MET/C BT Behav PET Skills Pharm Other PAU No Tx Family Indiv Cons Mixed Cons X CBT 3 X MET X 1 X X MET/CBT X 1 1 Behavioral 1 X X 1 X 1 1 PET 5 X X X 3 2 Skills Trng 2 X X X 1 X X 3 Pharm X X X X X X X X X 7 Other 1 X X 1 X X X X X X 1 1 Prac Usual 3 X X 1 1 X 1 X X X 3 No Tx X X X 2 9 X X 2 X 7 1 X

16 N of Studies for Each Comparison of Treatment Conditions Fam Ind C Mix C CBT MET MET/C BT Behav PET Skills Pharm Other PAU No Tx Family Indiv Cons Mixed Cons CBT MET MET/CBT Behavioral PET Skills Trng Pharm 7 Other Prac Usual No Tx

17 Effect Size for Comparing Outcomes of Different Treatment Conditions Substance Use Posttest Effect Size [Δ/sd p ] Before (pretest) After (posttest)

18 Comparative Effectiveness of Different Treatments

19 Comparative Effectiveness of Different Treatments

20 Summary: Comparative Effectiveness Categories Better outcomes than (almost) any comparison condition Family therapy (p<.05) MET (p<.05, often compared with no treatment ) CBT (n.s.) Pharmacological (n.s., only compared with placebos) Better outcomes than some comparison conditions, worse than others MET/CBT (n.s.) Mixed counseling (n.s.) Behavioral therapy (n.s.) Worse outcomes than most conditions, but may be better than nothing PET (n.s.) Skills training (p<.05) Individual counseling (p<.05) Practice as usual (n.s.) Actually or presumptively ineffective All other treatments (p<.05) Placebo control (n.s., for pharmacological Tx only) No treatment (p<.05)

21 Effect Sizes for the More Effective Treatments Treatment k n Mean ES vs PET k n Mean ES vs. Practice as Usual k n Mean ES vs. All a Available Family therapy MET CBT b Note: Effect sizes adjusted for method and participant characteristics. k = number of studies; n = number of effect sizes. a Excluding no treatment comparison conditions when used. b Large number of unfavorable comparisons with family therapy.

22 Another Approach: Pre-Post Change in Each Treatment Arm Substance Use Before (pretest) After (posttest)

23 Effect Size for Comparing Outcomes of Different Treatment Conditions Substance Use Pre-Post Effect Size [(p 2 -p 1 )/sd p ] Before (pretest) After (posttest)

24 Effect Size for Comparing Outcomes of Different Treatment Conditions Substance Use Pre-Post Effect Size [(p 2 -p 1 )/sd p ] Before (pretest) After (posttest)

25 The Treatment Conditions with Pre-Post Arms The original 48 experimental or quasi-experimental treatment comparison studies provided 98 pre-post arms for treatment or control conditions. Change (improvement) in substance use is represented by 311 pre-post effect sizes 45% alcohol (n=139) 13% marijuana/cannabis (n=40) 34% mixed substances (n=105) 9% other specific substances (e.g., cocaine; n=27)

26 Adjusted Mean Pre-Post Effect Sizes by Treatment Condition Treatment Condition Mean Effect Size and 95% Confidence Interval Estimates adjusted for drug outcome type, method, and participant characteristics.

27 Differential Improvement for Different Substances Substance Use Outcome k n All substances combined Mean Effect Size Mixed substances Marijuana Alcohol Other substances Effects on alcohol and other drugs significantly smaller than effects on mixed substances and marijuana Across all treatment conditions, there is less improvement after treatment for use of alcohol and other drugs than for use of marijuana.

28 Adolescent Characteristics Associated with Improvement Characteristics of Adolescent Participant Sample Regression Coefficient* % males in sample.13 % white participants in sample -.10 Average age -.10 Clinically comorbid participants (yes/no).01 Delinquency level (low to high) -.23 None of these relationships are statistically significant Baseline substance severity (low to high) -.10 * Standardized regression coefficient with controls for type of drug use outcome and method characteristics. Improvements in substance use were not related to any of the characteristics of the adolescent participants that could be examined.

29 General Treatment Characteristics Associated with Improvement Treatment Characteristics Regression Coefficient* Frequency of treatment contact.20 Treatment duration (weeks) -.31 p <.05 Implementation scale (low to high) -.01 * Standardized regression coefficient with controls for type of drug use outcome, participant characteristics, and method characteristics. Among these few dose and implementation variables, longer treatment duration was associated with less improvement.

30 The GAIN Data 103 outpatient treatment programs serving over 9,000 adolescents (27 of these programs are represented in the previous analyses). Predominantly male clients (average 73% male across programs). Mixed race/ethnicity: 48% White, 22% Hispanic, 15% African American, and 15% other minority. Average age at intake was 16.

31 Substance Use Histories Multiple substances used: 82% presented with alcohol use, 90% with marijuana use, and 59% with illicit drugs other than alcohol or marijuana. Adolescents primary substance was predominantly marijuana (61%). Significant proportions had antisocial/delinquent and/or mental health histories: 45% with court or probation contact 63% with co-occurring mental health symptoms

32 Treatment Conditions Treatment Number of programs Number of youth ACRA Family Programs FSN MDFT MST 2 71 MET/CBT & CBT MET/CBT MET/CBT MET/CBT CBT 2 185

33 Treatment Conditions (continued) Treatment Number of programs Number of youth Other Treatment Challenges Chestnut Health model Thunder Rd. IOP 1 16 EMPACT Generic family therapy 2 57 Group therapy Motivational interviewing Student Assistance 3 83 Case management Outpatient unspecified 4 208

34 Substance Use Outcomes Composite variable indexing substance issues, abuse, dependence, and problems, frequency of use, and abstinence. Not drug-specific 6-month post-intake outcomes used in analysis providing that it occurred after treatment and had less than 50% attrition. Treatment outcomes analyzed as reductions in substance use problems from intake to posttest. Across all treatments, substance use problems were significantly lower (better) at posttest than at intake.

35 Adolescent Characteristics Associated with Improvement Treatments with larger proportions of males exhibited smaller reductions in substance use problems (β =.19*). Treatments with larger proportions of youth with mental health histories exhibited smaller reductions in substance use problems (β =.37*). Treatments with higher proportions of clients with alcohol use problems exhibited smaller reductions in substance use problems (β =.21*). Note: regression coefficients are standardized; *p <.05.

36 Treatment Characteristics Associated with Improvement Treatment length and treatment completion rate were not significantly associated with outcomes. For the four categories of treatment types: The group of other treatments showed significantly larger reductions in substance use problems than ACRA, MET/CBT & CBT, and the specific family programs. ACRA, MET/CBT & CBT, and specific family program groups each showed reductions in substance use problems but were not significantly different from each other.

37 Post-treatment Reductions in Substance Use Problems for the Broad Treatment Groups Treatment Group Mean Reduction and 95% Confidence Interval

38 Overall Highlights Many studies of treatment for adolescent substance use disorders have been conducted, but they mainly compare different treatments with each other. The body of controlled studies clearly shows that some treatments work, i.e., reduce substance use for youth with clinical levels of abuse or dependence. Family therapy, MET, CBT, & MET/CBT treatment modalities showed the largest and most consistent relative effects; generic individual counseling, skill training, and PET showed the smallest.

39 Overall Highlights (continued) Longer treatment duration was associated with somewhat smaller effects but, overall, specific treatment characteristics had little influence on outcomes. Treatment had smaller effects on alcohol and other drug use than on marijuana use. Adolescents demographic and risk characteristics had no relationship to treatment effects in the research studies but, in the GAIN provider data, client groups with more mental health history and more males showed smaller effects.

40 That s it for now!

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