Interventions for Transition Age Youth with Co occurring Mental - - PowerPoint PPT Presentation

Interventions for Transition Age Youth with Co‐

• ccurring Mental Health and Substance Use Issues

Sherry Larkins, Ph.D. UCLA Integrated Substance Abuse Programs September 7, 2011

Agenda

Review importance of epidemiological data – understand adolescent substance issues. Review substances of abuse and how addictions develop Review standardized screening & assessment infrastructure to support the move to improve treatment effectiveness Review clinical strategies deemed EB as brief treatments/interventions for adolescents with co-occurring MH and SUD

The Spectrum of Interventions

Prevention/ Education Formal Specialized Treatments *Brief Treatments Brief Advice *Brief Interventions

3

Dennis, 2002

10 20 30 40 50 60 70 80 90 100

12 13 14 15 16 17 18 19 20 21 22-23 24-25 26-29 30-34 35-39 50-64 65 +

Alcohol Use Tobacco Use Binge Alcohol use Any Illicit Drug Use Marijuana Use

Substance Use Disorders are Adolescent Onset Disorders

Research shows that 90% of all adults with dependence started using under the age of 18, half of which were under the age of 15.

Where have we been?

Past decade, adolescent substance use field has gained growing attention

Moving away from adult paradigm

Since 1997 research has grown tremendously

Supported the field as an “emerging science”

Adolescent Substance Abuse Research Adolescent Substance Abuse Research

Feature 1930-1997 1997-2009

Treatment Studies 16 500+ Random/Quasi 9 48+ Tx Manuals 50+ QA/Adherence Rare Common Practice Epidemiology Studies Slow Common Tracking Evaluations Descriptive/Simple More Advanced Economic Some Cost Cost, CEA, BCA

Growth has helped shape service improvement agendas

What does Epidemiology Research Tell Us about Adolescent Substance Use Problems?

National Survey Data: Substance Abuse/Dependence among Youth (12-17)

National Survey on Drug Use and Health 20 0 2– 20 0 9

Clinical Concern: Whose Presenting for Treatment?

National Treatment Data: Adolescent Admissions by Primary Substance of Abuse/Dependence

Treatment Episode Data Set (1996-2006)

Com m on Use Trends…

Mainstay Substances

• Tobacco
• Alcohol
• Marijuana

Hot Issues at the National front

• Prescription & over-counter medications
• Inhalants
• Club Drugs (MDMA – “x”)

Where are adolescents at with harder drugs?

• Harder Drugs – meth, cocaine, heroin

Access & Availability

Every Generation of Teens Looks for New Ways to Get “High”

Substance Use Disorders Onset in Adolescents

Source: Dennis et al 2008 10 20 30 40 50 60 70 80 90 100 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 65+ No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence NSDUH Age Groups Severity Category

Adolescent Onset Remission

Progression of Use

FAS---Substance use in-uterus No Social Use Experimentation Use Use Abuse Dependence

• 0-2 3-5 6-8 9-10 11-12 13-14 15-16 17+

Infant Child Pre- Adolescent adolescent Mental Health Disorder’s onset---------------------------------- Use: Isolation with substance-loss of relationships Abuse: DMS IV Dependence: DSM IV

Onset of Mental Health Disorders

• Oppositional Defiance 5y/o
• Attention Deficit Disorder-ADHD 1.3-2.4
• Anxiety Disorders 3.8
• Conduct Disorder 5.6
• Depression 10.1
• Schizophrenia-affective disorders

» Teen years and mid-thirties

Continuum of Adolescent Substance Use

Clinical Risk & System Response

Pre Use Abstinence Substance Dependence Substance Abuse 15% of the Population 15% of the Population

70% of the Population

Experimental Use Social/Recreational Use Misuse Primary Prevention Services Traditional Treatment Secondary Prevention Brief Intervention = Educational Brief Intervention Brief Treatment

Source: SBIRT Project 2007, Stephen O’Neil

Clinical Trajectory

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Review of Psychoactive Drugs

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Classifying psychoactive drugs

Depressants Stimulants Hallucinogens

Alcohol Amphetamines LSD, DMT Benzodiazepines Cocaine Mescaline Opioids Nicotine PCP Solvent/Inhalants MDMA/Ecstasy Ketamine Barbiturates Khat Cannabis (high doses) Cannabis (low doses) Caffeine Mushrooms “Bath Salts” MDMA

Why do people initiate drug use? (1)

To Feel Good

Novel Feelings Sensations Experiences AND To share them

To Feel Better

Lessen: Anxiety Worries Fears Depression Hopelessness Withdrawal

Why Do People Initiate Drug Use (2) ?

Curiosity Availability Peer Pressure To have fun Gain Energy Lose Weight Reduce Pain

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What is drug addiction?

Drug addiction is a complex illness characterised by compulsive, and at times, uncontrollable drug craving, seeking, and use that persist even in the face of extremely negative consequences.

Behavioral Responses How Drugs Work



Loss of control limiting intake



Continued compulsive use despite harmful consequences



Characterized by craving, tolerance, withdrawal



Multiple relapses preceding stable recovery

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Craving

Psychological craving is a strong desire or urge to use drugs. Cravings are most apparent during drug withdrawal.

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Tolerance

Tolerance is a state in which a person no longer responds to a drug as they did before, and a higher dose is required to achieve the same effect.

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Withdrawal

The following symptoms may occur when drug use is reduced or discontinued:



Tremors, chills



Cramps



Emotional problems



Cognitive and attention deficits



Hallucinations



Convulsions



Death

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How Does an Addiction Develop?

Classical Conditioning: Addiction

• Over time, drug or alcohol use is paired with cues

such as money, paraphernalia, particular places, people, time of day, emotions

• Through classical conditioning these cues are

paired with pleasurable effects of the drug (“high”).

• Eventually, exposure to cues alone produces

drug or alcohol cravings or urges that are often followed by substance abuse

Pathway for Understanding Addictive Effects

• f Drugs on the Brain & Behavior

Reward Pathway

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The reward system

Natural rewards



Food



Water



Sex



Nurturing

50 50 100 100 150 150 200 200 60 60 120 120 180 180

Time (min) Time (min)

% of Basal DA Output % of Basal DA Output

NAc shell NAc shell

Empty Empty Box Box Feeding Feeding Source: Di Chiara et al. Source: Di Chiara et al.

FOOD FOOD

100 100 150 150 200 200 DA Concentration (% Baseline) DA Concentration (% Baseline)

Mounts Mounts Intromissions Intromissions Ejaculations Ejaculations

15 15 5 5 10 10

Copulation Frequency Copulation Frequency Sample Number Sample Number 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 Scr ScrScr Scr Bas BasFemale 1 Present

Female 1 Present

Scr Scr

Female 2 Present Female 2 Present

Scr Scr

Source: Fiorino and Phillips Source: Fiorino and Phillips

SEX SEX

Natural Rewards Elevate Dopamine Levels Natural Rewards Elevate Natural Rewards Elevate Dopamine Levels Dopamine Levels

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Activating the system with drugs

Source: Shoblock and Sullivan; Di Chiara and

Effects of Drugs on Dopamine Release Effects of Drugs on Dopamine Release

100 100 200 200 300 300 400 400 Time After Cocaine Time After Cocaine % of Basal Release % of Basal Release DA DA DOPAC DOPAC HVA HVA Accumbens Accumbens

COCAINE COCAINE

100 150 200 250 1 2 3 4hr Time After Ethanol % of Basal Release 0.25 0.5 1 2.5 Accumbens Dose (g/kg ip)

ETHANOL

100 100 150 150 200 200 250 250 1 1 2 2 3 hr 3 hr Time After Nicotine Time After Nicotine % of Basal Release % of Basal Release Accumbens Accumbens Caudate Caudate

NICOTINE NICOTINE

Time After Methamphetamine % Basal Release

METHAMPHETAMINE

1 2 3hr 1500 1000 500 Accumbens

Prolonged Drug Use Changes the Brain In Fundamental and Long-Lasting Ways

BRAIN CHANGES appear prominently in PET scans of current and past drug users Drug users have far less dopamine activity (right), as is indicated by the depletion (dark red shows disruption), compared to the controls (left) Studies show that this difference contributes to dependence and a diseased brain

Control > MA

4 3 2 1

MA > Control

5 4 2 1 3

Clinical Situation is Complicated

Problem Severity

Clinical Risk & System Response

Pre Use Abstinence Substance Dependence Substance Abuse 15% of the Population 15% of the Population

70% of the Population

Experimental Use Social/Recreational Use Misuse Primary Prevention Services Traditional Treatment Secondary Prevention Brief Intervention = Educational Brief Intervention Brief Treatment

Source: SBIRT Project 2007, Stephen O’Neil

Clinical Trajectory

Complexities for Clinical Tx

Majority of adolescents presenting for tx with more than just substance use problems…

Psychological co-occurring (trauma, depression, anxiety, etc.) histories Delinquent/legal court/probation issues School drop-out/academic failure issues Family dysfunction

Clinical Risk Differs Clinical Risk Differs

Understanding Problem Severity

Screening is essential To determine RISK - the actual problem severity– where are they along the clinical risk continuum of use? Standardized Screeners

CRAFFT: Eng/Span

Knight et al. 2002

Client Screening Activity

Responsibility element Coping element – use moves beyond pleasure Isolation/Social Withdraw element Impairment element Problem Use recognized by others Consequences of use*

Interviewing for interconnected problems

Medical S u b s t a n c e U s e M e n t a l H e a l t h

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Children’s Forms – Being Revised?

Los Angeles DMH Assessment

SUD Mental Health

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Los Angeles DMH Assessment

Mental Health Considerations

Depression Anxiety Anhedonia Psychotic Thinking Trauma/PTSD Confusion Memory Issues …

Medical Considerations

Cirrhosis Gastroenteritis Abscess Diabetes High Blood Pressure HIV/HCV Cardiac Problems TB …

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The Spectrum of Interventions

Prevention/ Education Formal Specialized Treatments *Brief Treatments Brief Advice *Brief Interventions

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Continuum of Adolescent Substance Use

Turn Our Attention to: Treatment Effectiveness Studies

Tell us about the effectiveness of different treatment models for adolescents with substance use disorders Includes studies with programs deemed “evidence-based” Proven to be successful through research methodology and have produced a consistent pattern of positive results.

EBP Brief Treatment Series

Cannabis Youth Treatment Trials

CYT

• 1. Motivational Enhance Treatment/Cognitive

Behavior Therapy (MET/CBT5)

• 2. Cognitive Behavior Therapy 7 (CBT7)
• 3. Family Support Network (FSN)
• 4. Adolescent Community Reinforcement

Approach (ACRA)

• 5. Multidimensional Family Therapy (MDFT)

Treatment Series

P e e r S a d n e s s

Negative Emotions

SUD

Family

Physical Problem

Negative Emotions

Mental Health

SUD

Difficult Clients are Categorized as…

Main problem: AOD/SUD contributes to their MH issues The client perception of the issue: XXX B/C Disconnect & Mismatch Resistance Distrust Poor Insight/Awareness Low motivation

5 Manualized Tx Protocols

Treatment manuals available from National Clearinghouse for Alcohol and Drug Information (NCADI) or www.chestnut.org/li

Motivational Enhanced Treatment/ Cognitive Behavior Therapy 5 (MET/CBT5)

Cannabis Youth Treatment Trials

CYT

Treatment Series Volume 1

Sampl, S., & Kadden, R. (2001)

University of Connecticut Health Center Farmington, CT USA

Individual MET (MI) Sessions 1 & 2

(50-75 min)

• 1. Assessment Feedback (Review PFR), Rapport-

Building, Orientation to Treatment

• 2. Review of Progress, Functional Analysis,

Personalized Goal Setting, and Orientation to the Group Sessions

Group CBT Sessions 1-3

(50-75 Min)

• 1. Drug/ETOH Refusal Skills
• 2. Increasing Social Support

and Pleasant Activities

• 3. Coping with Emergencies

and Relapse Client Preparedness

Plus 2 Random Urines over six weeks

Cognitive Behavior Therapy 7 Supplement (CBT-7)

Cannabis Youth Treatment Trials

CYT

Treatment Series Volume 2

Webb, C., Scudder, M., Kaminer, Y., Kadden, R., & Tawfik, Z. (2002)

University of Connecticut Health Center Farmington, CT USA

7 Supplemental CBT Sessions:

• 6. Problem-Solving Skills
• 7. Anger Awareness
• 8. Anger Management
• 9. Communication Skills: Assertiveness and Criticism
• 10. Coping with Cravings
• 11. Managing Negative Moods
• 12. Managing Thoughts about Using

Stages of Change

Prochaska & DiClemente

How you talk to the adolescent matters

You are singing off key if you find yourself…

• Challenging
• Warning
• Finger-wagging
• Moralizing
• Giving unwanted

advice

• Shaming
• Labeling
• Confronting
• Being Sarcastic
• Playing expert

Five Strategies of MET

• 1. Express Empathy
• 2. Develop Discrepancy
• 3. Avoid Argumentation
• 4. Roll with Resistance
• 5. Support Self-Efficacy

Facilitating the Risk/Reward Analysis

What to focus on: Decisional balance scale

Elicit pros and cons of use and change Emphasize client choice and responsibility

Elicit self-motivational statements, and summarize them (they are hearing what they just said)

How do you avoid argumentation with a teenager?

Resistance should be a CUE to modify your approach Treat ambivalence (mixed feelings) as normal

Bring the focus back on their concerns:

Elicit the client’s perceptions of the problem and providing feedback

Video Demo:

Goal Setting (MET) & Increasing Social Support/Pleasant Activities (CBT) & Coping with Emergencies

Family Support Network (FSN)

Cannabis Youth Treatment Trials

CYT

Treatment Series Volume 3

Hamilton, N., Brantley, L., Tims, F., Angelovich, N., & McDougall, B. (2001). Operation PAR

• St. Petersburg, FL USA

I mportance of the Family! I mportance of the Family!

Substance Use Correlations

Intraclass Correlations w

3-month 6-month 9-month 12- month 95% C.I. Family conflict .56 .48 .47 .43 .58 (.53, .62) Family cohesion .56 .50 .46 .50 .54 (.50, .59) Social support .42 .38 .45 .44 . 50 (.45, .54) Recovery environment risk .42 .42 .37 .24 .43 (.39, .48) Social risk .28 .34 .24 .21 .37 (.32, .42) Substance use .36 .30 .19 .27 .50 (.45, .54) Substance-related problems .43 .35 .31 .31 .46 (.42, .51)

A Closer Look at the Family Issue…

Family Support: less family conflict and greater family cohesion corresponded to reduced risk for poor treatment outcomes Although families play a pivotal role, they vary in their ability and willingness to help…

How do you facilitate Parental Attendance?

Adolescent Community Reinforcement Approach (ACRA)

Cannabis Youth Treatment Trials

CYT

Treatment Series Volume 4

Godley, S. H., Meyers*, R. J., Smith*, J. E., Godley, M. D., Titus, J. M., Karvinen, T., Dent, G., Passetti, L., & Kelberg, P. (2001). Chestnut Health Systems Bloomington, IL USA, and *University of New Mexico Albuquerque, NM USA

Multidimensional Family Therapy (MDFT)

Cannabis Youth Treatment Trials

CYT

Treatment Series Volume 5

Liddle, H. A. (2002). University of Miami Miami, FL USA

2010 Meta-Analysis

Study of studies conducted to identify treatment effectiveness of various EBP treatment approaches that maximize treatment outcomes (JMATE presentation)

48 studies that included 79 treatment approaches for adolescents

Treatment Approaches

Family therapy (k = 25, n = 88) Individual counseling Generic GROUP counseling Cognitive behavioral therapy (CBT) Motivational interviewing/enhancement therapy (MET) MET + CBT (MET/CBT) Psychoeducational therapy (PET) Contingency Management Vocational counseling Drug court

• Pharm. treatment

No Treatment

Results

Effect sizes were close and not statistically meaningful to make definitive statements about superiority…BUT

Family therapy & CBT/MET combo had stronger effects (on abstinence

• utcomes) than all compared treatment

conditions Individual counseling was less effective than all other treatment conditions with which it was compared

The Post-Treatm ent Period

In-Tx Factors In-Tx Factors

Recovery

Treatment Effectiveness Studies

Important to note: studies have NOT established a superior treatment approach

They all have equally effective results in terms of producing positive outcomes…

Reducing use Improving mental health/wellbeing, and Repairing social relations

Happy Ending?

Treatment Outcome Studies Treatment Outcome Studies

Although treatment is working…

Less than half of adolescents leave treatment with a positive discharge (still using) Relapse continues to be fairly common: ~65% relapse during first three months after tx completion (Brown et al., 1989) and longer-term (12 mos; Dennis et al.,2000) Lack of continuity of care: less than 10% participate in aftercare after formal tx

Been called many things Been called many things… …

Aftercare Continuing care Stepped-down care Extended interventions Disease management

McKay (2008)

Continuing Care Service Barriers

• Limited funding for services in the

addiction field

• Limited availability of services
• Hence, not a standard “clinical” practice
• Why pay when we have – 12 step model?
• Been referred to as “the perfect aftercare” (White,

2007)

Em pirical Support for CC

Evidence suggests clients who get continuing care have better outcomes than clients who do not receive CC services (McKay, 2009).

• Evidence mainly established for adults; less

clear for adolescents

• Very few continuing care studies of adolescents in

the scientific literature

• Godley et al. 2002 – home visits with youth after

residential tx (Assertive Continuing Care)

Brief Intervention

FLO

The 3 Tasks of a BI

Avoid Warnings!

F L O W

Feedback Listen & Understand Warn Options Explored

(that’s it)

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How does it all fit together?

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The 3 Tasks of a BI

F L O

Feedback Listen & Understand Options Explored

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The First Task: Feedback

Your job in F is only to deliver the feedback! Let the consumer decide where to go with it. Ask for Permission explicitly

There’s something that concerns me. Would it be ok if I shared my concerns with you?

Provide direct feedback

The results of your screening form suggest that…

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The First Task: Feedback

Handling resistance…

• Look, I don’t have a drug problem
• I just like to party with my friends
• I can quit using anytime I want to
• I just like the taste
• I’m young, what’s the big deal?

What would you say?

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To avoid this…

LET GO!!!

The First Task: Feedback

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The First Task: Feedback

Easy Ways to Let Go…

• I’m not going to push you to change anything you

don’t want to change…

• I’m not hear to convince you that you’re partying

too much…

• I’d just like to give you some information...
• I’d really like to hear your thoughts about…
• What you do is up to you….

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Feedback: Content Areas for Adolescents

Alcohol Use Marijuana Use Prescription Medication Use Club drug use

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Always ask this question: “What role, if any, do you think (substance) played in (problem) ?

The First Task: Feedback Let’s practice F: Role Play Giving Feedback ONLY

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The 3 Tasks of a BI

F L O

Feedback Listen & Understand Options Explored

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The Second Task: Listen and Understand

Listen for the change talk… Maybe drinking did play a role in what happened If I wasn’t partying, this would never have happened I don’t want to be in this mess again The last thing I want to do is hurt someone else I know I can quit because I’ve stopped before Summarize, so they hear it twice!

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The Second Task: Listen and Understand

Dig for change talk…

• I’d like to hear your opinions about…
• What are some things that bother you about

your use?

• What role do you think drugs/alcohol played in

________________?

• How would you like your drinking to be 5 years

from now?

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The Second Task: Listen and Understand

Tools for Change Talk

• Pros and Cons
• Importance & Confidence Scales
• Readiness Ruler

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The Second Task: Listen and Understand

Strategies for weighing the pros and cons…

• “What do you like about drinking?”
• “What do you see as the downside of drinking?”
• “What Else?”

Summarize both pros and cons… “On the one hand you said.., and on the other you said….

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The Second Task: Listen and Understand

Importance/Confidence/Readiness On a scale of 1–10…

• How important is it for you to change your drinking?
• How confident are you that you can change your

drinking?

• How ready are you to change your drinking?

For each ask…

• Why didn’t you give it a lower number?
• What would it take to raise that number?

1 2 3 4 5 6 7 8 9 10

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The Second Task: Listen & Understand

Let’s practice L:

Role Play Listen & Understand Using Completed Screening Tools

• Pros and Cons
• Importance/Confidence/Readiness Scales
• Develop Discrepancy
• Dig for Change
• Create movement in Consumer’s Stage of

Readiness for Change

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The 3 Tasks of a BI

F L O

Feedback Listen & Understand Options Explored

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What now? What do you think you will do? What changes are you thinking about making? What do you see as your options? Where do we go from here? What happens next?

The Third Task: Options for Change

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Offer a Menu of Options

• Manage drinking/use (cut down to low-risk limits)
• Eliminate your drinking/drug use (quit)
• Never drink and drive (reduce harm)
• Utterly nothing (no change)
• Seek help (refer to treatment)
• Set up appointment with prescribing physician

The Third Task: Options for Change

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During MENUS You can also explore previous strengths, resources and successes

• “Have you stopped drinking/using drugs before?”
• “What personal strengths allowed you to do it?”
• “Who helped you and what did you do?”
• “Have you made other kinds of changes successfully in

the past?”

• “How did you accomplish these things?”

The Third Task: Options for Change

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The Third Task: Options for Change

Giving Advice Without Telling Someone What to Do Ask for Permission explicitly There’s something that concerns me. Would it be ok if I shared my concerns with you? Preface advice with permission to disagree This may or may not be helpful to you

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Putting it all together

Feedback Range Pros and Cons Importance/Confidence/Readiness Scales Summary Options Explored Listen and Understand Menu of Options

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NIDA and SAMHSA Resources

“NIDA Red Book”

TIP 31: Screening & Assessing Adolescents for Substance Use Disorders TIP 32: Treatment of Adolescents With Substance Use Disorders For parents offer:

Contact Information Contact Information

Sherry Larkins larkins@ucla.edu

UCLAISAP www.uclaisap.org