E-Based Treatment Articles (ODADAS Deliverables) - DOC by xri73186


									                            E-Based Treatment Articles
    Clinical Brief: Evidence-Based Practices for Adolescents with Co-Occurring
                          Eric R. Baltrinic MA. Ed., PCC, LICDC


   The purpose of this clinical brief is to provide addictions counselors with information
on what constitutes an “evidence-based practice” (EBP), give some examples of
evidence-based treatment components for adolescents with co-occurring disorders, and
provide information on existing research-based interventions-of varying levels of
evidence-that are being used to treat adolescents with co-occurring disorders. The target
audience is clinicians and service providers and is not intended to be a comprehensive
report on the issue.

                               Evidence-Based Practice
   Evidence-based practice is a term that we have been hearing about lately. It means that
the “practice” or treatment has been scientifically studied. Essentially, scientific methods
have been applied to study the impact of the treatment practices/processes on treatment
outcomes. Referral, assessment, case-management, and intervention processes are often
the subject of study. The overall intention of applying scientific methods to study the
process treatment is to get at the following questions:

                           How well does this treatment work?

                              With whom does it work best?

 What aspects of this treatment are essential to use in order to get the best results?

                Does the treatment do what it says it will do (validity)?

            Does the treatment get similar results every time (reliability)?

   Not every “type” of treatment out there is “evidence-based.” It takes quite a bit of
time, money and patience to apply scientific methods to obtain the information needed.
Once information is gathered, it is still important to see if the “practice” can be repeated
with the same outcomes in other places-is the “evidence-based practice” replicable?

                         Why Have Evidence-Based Practices?

    Evidence-based practices provide a scientific framework for treatment, thus moving
treatment away from any tendencies to practice from a “folk medicine” perspective. This
essentially refers to the professional labeling the problem and course of treatment based

on anecdotal information and personal experience only: “I think this is the problem,
therefore it is, and this is what you need to do about it.” EBP’s assist professionals by
providing scientifically originated information that can be combined with the clinicians’
experiences and individualized for proper client care.

   EBP’s begin to offer a solution to the problem- “Is treatment effective for addiction?”
Methods for tracking and measuring treatment outcomes are essential for an EBP.
Fidelity measures are part of the process. This means that clinicians who are “doing” the
treatment are required to follow certain “essential” practices in order to maximize the
EBP’s potential to help clients. Data act as a type of “proof” that treatment works and can
contribute to positively influencing public perception regarding treatment outcomes.

    EBP’s can function to meet the standards of effective practice in the field of addiction
and offer consistently effective approaches to all consumers of treatment services. The
idea is that “all” consumers get the highest standard of care. The principles of effective
treatment in the field of addiction offer a common language for professionals which can
be met through the use of EBP’s (From NIDA (1999) Principles of Drug Addiction Treatment: A
research-based guide):

      No single treatment is appropriate for all
      Treatment needs to be readily available
      Effective treatment attends to the multiple needs of the individual
      Ongoing assessment and modification of treatment plans is essential to meet
       clients’ changing needs
      Remaining in treatment for an adequate period of time is critical for effectiveness
      Counseling and other behavior therapies are critical components for effective
      Medications are an important element of treatment for many clients
      Co-occurring disorders should be addressed and treated in an integrated way
      Medical detox is only the first stage of treatment (in cases where appropriate)
      Treatment does not need to be voluntary to be effective
      Continuous monitoring for possible drug use during the course of treatment is
      Treatment programs should include assessment for HIV/AIDS, Hepatitis B & C,
       TB, and other infectious diseases-modifying high risk behaviors should be
       addressed in the counseling process
      Recovery from addiction can be a long-term process and frequently requires
       multiple treatment episodes

          Levels and Characteristics of Evidence-Based Practices
  So, what are the characteristics of an evidence-based practice? What distinguishes an
“EBP” from any other type of treatment? The following information is offered to assist

the clinician and program specialist by providing some descriptions/criteria to evaluate
the quality and credibility of EBP’s that are reviewed.

                                     EBP Continuum

    Clinical practices/treatments fall on a continuum from no evidence to support the
efficiency/efficacy of the practice to limited evidence to an evidence-based practice.
Categorically, EBP’s can be distinguished on the continuum as (Adapted from Great Lakes

Evidence-Based: practice/program has proven through research methodology to be
successful in a clinical setting and produced consistently positive patterns of results over
time (Modified from P. Waters, Southern Coast ATTC).
Science-Based: information has been demonstrated carefully controlled settings, but has
not been demonstrated in “front-line” clinical settings.
Consensus-Based: experts within a given field believe the practices they endorse would
be evidence-based if studied, but adequate studies have not been conducted for the
practice to be considered evidence-based.
Expert-Based: A single individual or multiple persons thought to be knowledgeable are
interviewed, no studies to support practice.
Environmental Initiatives: these practices are not science-based, but do act to improve
the environment/site in the direction of adopting and broadly implementing evidence-
supported practices.

                                        EBP Levels

   This “level system” is intended to give clinicians and other professional some
descriptive information to keep in mind when searching for EBP to implement in your
own agency or practice. It refers to the “science” behind the practice in terms of what
degree and intensity as the EBP been subjected to (Adapted from Great Lakes ATTC):

EBP Level 5: This level is based on programs and principles that have been replicated
and documented in numerous refereed journals over time.
EBP Level 4: This level is based on programs and principles that have undergone either a
quantitative analysis of methods/outcomes, etc. or an expert/peer consensus process in
the form of a qualitative analysis.
EBP Level 3: This level is based on source documents (writings/description of
programs/methods etc.) that have been closely analyzed by an expert/peer consensus
process, which looks at the quality of the programs proposed implementation and
evaluation process. It can also be based on material that has appeared in one or a few peer
reviewed journals.
EBP Level 2: This level is based on programs and principles that have appeared in non-
peer reviewed professional publications or journals
EBP Level 1: This level is based on programs and principles that have been identified
and recognized as helpful including receiving awards, honors, or mentions.

   So, as you can see not all “evidence-based practices are created the same.” The
continuum and levels presented above can help professionals ask informed questions
about the credibility, effectiveness, and efficacy of a program. Essentially, one can
weigh any program materials against these dimensions prior to consideration of adopting
any particular EBP. In addition to viewing an evidence-based practice on the
“continuum” and “level” systems, it is also important then to apply minimum criteria
when evaluating the credibility and quality of an evidence-based practice on the clinical
level. Minimum clinical level criteria include (adapted from EBP-Substance Abuse
project/Northwest Frontier ATTC):

Research: The EBP has been subjected to scientific study that included randomized
clinical trials, quasi-experimental studies, or at least some form of less rigorously
controlled research design. Has the research been published in a peer reviewed journal?

Meaningful/Relevant Outcomes: Application of the EBP has resulted in benefits to the
individuals receiving the service. Specifically, it has helped consumers achieve desired
treatment outcomes relevant to treatment goals and objectives.

Standardized: The EBP has consistent standards that allow it to be replicated. This means
that if you decided to adopt and EBP there would be some reference to “how” to do it
preferably in a manualized format. Standardization typically involves a published
description of the service that clearly defines the nature, audience, and desired impact of
the service for the individuals receiving it. This means that thorough instructions are
available including printed materials and other tools needed to implement the practice.

Replicated: The interventions, services, and practices inherent in the EBP have been
studied in more than one setting and have yielded similar results.

Fidelity: A fidelity measure either exists or could be developed from available
information. Fidelity measures allow practitioners to verify that the intervention is being
implemented consistently in accordance to the protocol evaluated in the research.

                       Evidenced-Based Treatments for Adolescents

    So, while the information presented here about EBP is in no way comprehensive, a
basic definition and set of characteristics has been laid out in order to help you evaluate
EBP’s. The following represent current evidenced-based treatments being employed in
clinical practice for youth with substance use disorders. It is not intended to be a
comprehensive list. A review of each EBP is beyond the scope of this brief. Keep in mind
that each EBP has its own process, logistics, requirements, outcomes, tools, etc. Keep in
mind the requirements of the EBP, in terms of resource demand (staffing, finances,
consulting, training, etc.) in relation to the realities of your site/practice. Please consider
the following websites as a resource for checking out new evidenced-based practices as
they arise:

NIDA : http://www.nida.nih.gov/DrugPages/Treatment.html
CSAT : http://csat.samhsa.gov/
ATTC : http://www.nattc.org/index.html
NREPP: http://www.nrepp.samhsa.gov/find.asp

Evidence-Based Substance Use Treatments for Adolescents
    Motivational Enhancement Therapy (MET)
    Individual Cognitive Problem-Solving Therapy (Azrin et al.)
    Cognitive Behavior Therapy (CBT)
    Community Reinforcement Approach (CRA)
    Multisystemic Therapy (MST)
    Brief Strategic Family Therapy (BSFT)
    Multidimensional Family Therapy (MDFT)
    Parent Management Training (PMT)
    Cannabis Youth Treatment Series MET/CBT 5; 7; 12
    Family Support Network for Adolescent Cannabis Users (FSN) - for youth who
      meet ASAM criteria for level I (Outpatient) and level II (IOP)

    Let’s turn to look at some of the characteristics needed to effectively treat adolescents
with co-occurring disorders. The following treatment characteristics were identified
through an expert panel evaluation and consensus process. 144 programs were evaluated
in order to reveal the overlapping components. The evidence points to using a
combination of treatment modalities to target a broader range of problems as an effective
strategy when working with adolescents with co-occurring disorders. Keep in mind that
many of these “characteristics” are treatment components that are shared or overlap
across research-developed treatment modalities (P. Riggs, 2003):

        Treatment Characteristics for Adolescents with Co-Occurring Disorders

      Comprehensive, systematic evaluation to identify problems and treatment needs
       in multiple life domains including psychiatric comorbidity

      Use of empathic, supportive, and motivation-enhancing techniques to improve the
       therapeutic alliance, engagement and retention

      Use of behavioral techniques informed by urine toxicology results to promote and
       shape desired behaviors such as increasing pro-social behaviors and the
       discontinuation of drug/alcohol use

      Use of cognitive-behavioral and skills-building techniques delivered in an
       individual or group format to enhance self-efficacy, problem-solving, decision-
       making, anger management, communication, mood regulation, coping, and
       relapse prevention skills

      Techniques are used to help adolescents avoid high-risk situations, identify
       triggers for drug use, decrease association with drug-using peers, and encourage
       pro-social, enjoyable activities that are incompatible with substance use

      Family involvement in adolescent’s treatment that emphasizes the importance and
       role of parental monitoring and behavior management skills, the use of
       restructuring interventions to disrupt and correct dysfunction patterns of
       interaction, increase quality and nature of relationships and behaviors to improve
       overall family functioning

      Emphasis on relapse prevention including the development of a specific
       individualized plan to manage relapse and the need for continuing care

      Emphasis on providing developmentally appropriate interventions including
       specialized program components such as gender-specific or culture-specific

      Emphasis on the importance of integrating the assessment and treatment of co-
       occurring psychiatric and substance use disorders

      Focus on adequate training and ongoing staff development activities for
       counselors and program specialists

      Focus on evaluating treatment outcomes

   It is not entirely “certain” from a scientific standpoint that these are essential active
ingredients in treatment for youth with co-occurring disorders. Minimally, they are
shared components across a great many programs of varying degrees of efficacy and can
certainly be considered important clinical components for treatment (P. Riggs, 2003).

   Before looking at some specific interventions it is important to acknowledge that
current research supports the notion that treatment for co-occurring substance use and
psychiatric disorders needs to be integrated. Let’s take a look at “why” integrated
treatment is warranted and “what” integrated treatment means, particularly in relation to
substance use treatment only.

                               Why Integrate Treatment?

   A summary of research findings from NIDA, 1999; and Drug Strategies, 2002
regarding the impact of co-occurring disorders includes (P. Riggs, 2003):

Adolescents with substance use disorders and co-occurring psychiatric disorders have
poorer substance abuse treatment outcomes. It is probable that undiagnosed and
untreated psychiatric disorders reduce the likelihood of successful engagement, retention,

and completion of substance abuse treatment. At one time, admission to drug treatment
was not an option for individuals with co-occurring psychiatric disorders. Barring a
psychiatric emergency i.e. suicidal ideation/gestures, individuals were referred to mental
health facilities to stabilize prior to admission to drug treatment. Conversely, prospective
clients at mental health facilities were often referred back to drug treatment facilities to
“sober up” prior to engaging in services. This phenomenon can be referred to as
sequential treatment, which says one disorder needs addressed before treatment for the
other can occur.

   Parallel treatment has often been part of the “solution” and process for youth with co-
occurring psychiatric disorders. This means that youth receive mental health and
substance abuse services form separate providers, usually in separate facilities. This sets
the stage for youth to “fall through the cracks” in terms of their ability to engage and
manage the logistics and recommendations of separate treatment providers. Integrated
treatment assumes that co-occurring substance use and psychiatric disorders are treated
together in one facility, by one or a team of providers. This greatly reduces attrition and
provides support to youth and families receiving the service. EBP’s play a critical role in
assuring that treatment acknowledges the research’s position on co-occurring disorders,
the clinical needs for this population, and the guidelines for maximizing treatment

   Untreated psychiatric disorders often persist beyond successful drug treatment.
   • Substance abuse treatment helps to reduce the frequency of use and the number of
       abuse/dependence symptoms but has only indirect impact on emotional and
       behavioral problems (M. Dennis, 2004)

Pre-existing psychiatric disorders like ADHD will remain and even contribute to
potential relapse after a period of abstinence. Depression is unlikely to remit after
abstinence, particularly if it played a role in influencing the pattern of substance use.

Studies also indicate that treatment for co-occurring psychiatric disorders alone is not
likely to bring about abstinence or even significantly reduce substance use (Geller et al.,

The bottom line is that if co-occurring psychiatric disorders are not treated soon after the
admission into drug treatment, the chances of the youth “failing” i.e. dropping out,
continued use, committing crimes, etc, increases. This often means significant
consequences, like incarceration, in cases of treatment-mandated youth.
Conclusion: Treating one disorder in isolation is not sufficient

                      Research-Based Treatments for Adolescents

   Currently, there are no evidenced-based practices specifically designed and tested for
treating adolescents with co-occurring disorders. However, Rigg’s consensus criteria for
best practice with youth with co-occurring disorders can be used to highlight treatments
that have many of the components believed to be helpful. Of particular promise is a new

         intervention model designed specifically for youth with co-occurring disorders the
         Integrated Co-Occurring Treatment model (ICT). The following represent some of the
         interventions that are available and being employed in current clinical practice. It is not
         intended to be a comprehensive list. A review of each EBP is beyond the scope of this

         Figure 1. Co-Occurring Treatments Matrix* (Based on Rigg’s Best Practice
                             ICT    MDFT             MST               BSFT     MET        CBT    ACRA
1    Comprehensive           Yes    Comprehensive    Comprehensive     SU       SU         SU     SU
     multiple life domain    MH     life domain      life domain
     assessment              & SU   assessment       assessment
     (including MH &                Focus: SU        Focus: MH
     SU)                                             externalizing
2    Supportive              Yes    Yes              Yes               Yes      Yes        Yes    Yes
3    Behavioral              Yes    Yes              Yes               No       Yes        Yes    Yes
     techniques informed                                                        Feedback
     by urine toxicology
     results to promote
     pro-social behaviors
     & environments
4    Individual cognitive-   Yes    Limited          No                No       No         Yes    Yes
     behavioral & skills-
5    Treatment focuses       Yes    Yes              Yes               Yes      Yes        Yes    Yes
     on reducing risk &                                                         Feedback
     increasing positive
     assets and resources
6    Family focus to         Yes    Yes              Yes               Yes      No         No     Yes
     improve family
7    Relapse prevention      Yes    Not explicitly   No                No       Yes        Yes    Yes
     & continuing care
8    Developmentally,        Yes    Yes              Yes               Yes      Yes        Yes
     gender, & culturally
9    Integrated              Yes    No               No                No       No         No     No
     assessment &
     treatment of MH &
10   Ongoing training        Yes    Yes              Yes               Yes      Yes
     and staff                                                                  (MINT)     *      *
11   Focus on evaluating     Yes    Yes              Yes               Yes      Yes        Yes    Yes
     treatment outcomes

*Not as part of manual, which is designed to “stand alone” but support and training are

Key to Co-Occurring Best Practice Matrix:
Integrated Co-Occurring Treatment (ICT)
Multidimensional Family Therapy (MDFT)
Multisystemic Therapy (MST)
Brief Strategic Family Therapy (BSFT)
Motivational Enhancement Therapy (MET)
Cognitive Behavior Therapy (CBT):
Community Reinforcement Approach (CRA)


   In summary, while a great deal of information exists regarding effective treatments
for adolescents, more work needs to be done; particularly in the area of integrated
treatment for adolescents with co-occurring disorders. Fortunately, this work is

   Evidence-based practices can provide a consistent quality driven service to treatment
consumers. The selection of an evidence-based practice warrants reviewing the practice
in question in relation to the level and nature of the “evidence” that supports it. It is
important to weigh the costs and benefits of selection and adopting an evidence-based
practice in your setting prior to implementation.


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