Understanding and Managing Addiction as a Chronic Condition Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation at the Congressional Addiction, Treatment, and Recovery Caucus Briefing, “Reducing Health Care Costs: Chronic Disease Management for Alcohol & Drug Problems,” June 11, 2009 from 1:00-3:00 p.m., 122 Cannon House Office Building. This presentation was supported by funds from and data from NIDA grants no. R01 DA15523, R37-DA11323, CSAT contract no. 270-07-0191 and several other authors/studies. It is available electronically at www.chestnut.org/li/posters. The opinions are those of the author and do not reflect official positions of the government. I would like to thank Redonna Chandler, Wilson Compton, Mark Godley, Thomas Hilton, Randy Muck, Chris Scott, and Alan Sender, for their assistance in preparing this presentation. Please address comments or questions to the author at mdennis@chestnut.org or 309-451-7801. .p Thank you… I would like to start by acknowledging that this presentation builds on a series of studies and papers the Chris Scott, and I have done… as well as data from the several large community and clinical epidemiological data bases made available to the public by the U.S. Government. Also note that i have posted an electronic copy of this presentation at www.chestnut.org/li/posters

The Goals of this Presentation are to: Illustrate the chronic nature of substance use disorders Examine the likelihood and nature of sustained recovery Demonstrate the feasibility of using simple protocols like recovery checkups to improve long-term outcomes

Normal levels of brain activity in PET scans show up in yellow to red Prolonged Substance Use Injures The Brain: Healing Takes Time Normal levels of brain activity in PET scans show up in yellow to red Normal Reduced brain activity after regular use can be seen even after 10 days of abstinence 10 days of abstinence After 100 days of abstinence, we can see brain activity “starting” to recover Slide 8: Long-term effects of drug abuse The images in these PET scans, which depict brain glucose utilization (a marker of brain activity), show that once the brain becomes addicted to a drug like cocaine, it is affected for a long, long time. In other words, once addicted, the brain is literally changed. Let’s see how.   In this slide, increasing amounts of brain function are measured by yellow or red. The top row shows a normal functioning brain without drugs. You can see a lot of brain activity. In other words, there is a lot of yellow and red color. The middle row shows a cocaine addict’s brain after 10 days without any cocaine use at all. What is happening here? [Pause for response.] Less yellow and red means less normal activity occurring in the brain—even after the cocaine abuser has abstained from the drug for 10 days. The third row shows the same addict’s brain after 100 days without any cocaine. We can see a little more yellow and red, so there is some improvement— more brain activity—at this point. But the addict’s brain is still not back to a normal level of functioning. . . more than 3 months later. Scientists are concerned that there may be areas in the brain that never fully recover from drug abuse and addiction. 100 days of abstinence Source: Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.

Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20 100 People with drug dependence die an average of 22.5 years sooner than those without a diagnosis Over 90% of use and problems start between the ages of 12-20 90 Percentage 80 It takes decades before most recover or die 70 60 Severity Category 50 Other drug or heavy alcohol use in the past year 40 30 Alcohol or Drug Use (AOD) Abuse or Dependence in the past year This figure shows how the prevalence of these past year severity categories vary by age. 1- Substance use disorders typically on set during adolescents and young adult hood. In fact, 90% of all adults with dependence started using under the age of 18, half under the age of 15. 2- After several decades, the rates of abuse and dependence do decrease as people go into remission, incarceration or die. Epidemiological studies of people with lifetime substance dependence suggest that 58% eventually enter sustained recovery (i.e., no symptoms for the past year) -- a rate that is considerably better than the 39% average rate of recovery across psychiatric disorders (Kessler, 1994; see also Dawson, 1996; Robins & Regier, 1991). 3 – Notice how the rates of no use go up with age. Thus substance use disorders on set early and last for many years, but do get better over time. *2002 U.S. Household Population estimated to be 235,143,246 20 10 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Age Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000

Substance Use Disorders are Common, But Treatment Participation Rates Are Low Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Few Get Treatment: 1 in 17 adolescents, 1 in 22 young adults, 1 in 12 adults Much of the private funding is limited to 30 days or less and authorized day by day or week by week Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

People Entering Publicly Funded Treatment Generally Use For Decades It takes 27 years before half reach 1 or more years of abstinence or die 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent still using Years from first use to 1+ years of abstinence 5 10 15 20 25 30 Source: Dennis et al., 2005

The Younger They Start, The Longer They Use Age of First Use 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent still using Age of First Use Years from first use to 1+ years of abstinence 60% longer under 15 15-20 21+ 5 10 15 20 25 30 Source: Dennis et al., 2005

Years to first Treatment Admission The Sooner They Get The Treatment, The Quicker They Get To Abstinence Years to first Treatment Admission 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent still using 20 or more years Years from first use to 1+ years of abstinence 57% quicker 10 to 19 years 0 to 9 years 5 10 15 20 25 30 Source: Dennis et al., 2005

After Initial Treatment… Relapse is common, particularly for those who: Are Younger Have already been to treatment multiple times Have more mental health issues or pain It takes an average of 3 to 4 treatment admissions over 9 years before half reach a year of abstinence Yet over 2/3rds do eventually abstain Treatment predicts who starts abstinence Self help engagement predicts who stays abstinent Source: Dennis et al., 2005, Scott et al 2005

The Likelihood of Sustaining Abstinence Another Year Grows Over Time After 4 years of abstinence, about 86% will make it another year After 1 to 3 years of abstinence, 2/3rds will make it another year 100% . Only a third of people with 1 to 12 months of abstinence will sustain it another year 86% 90% 80% 66% 70% 60% % Sustaining Abstinence Another Year 50% 36% 40% 30% 20% A key question that is often asked is how long someone is at risk of relapse. This figure shows the odds of sustaining relapsed from year 7 to year 8 based on the duration of abstinence. 10% 0% 1 to 12 months 1 to 3 years 4 to 7 years Duration of Abstinence But even after 7 years of abstinence, about 14% relapse each year Source: Dennis, Foss & Scott (2007)

What does recovery look like on average? Duration of Abstinence 1-12 Months 1-3 Years 4-7 Years More clean and sober friends Less illegal activity and incarceration Less homelessness, violence and victimization Less use by others at home, work, and by social peers Virtual elimination of illegal activity and illegal income Better housing and living situations Increasing employment and income More social and spiritual support Better mental health Housing and living situations continue to improve Dramatic rise in employment and income Dramatic drop in people living below the poverty line Source: Dennis, Foss & Scott (2007)

Sustained Abstinence Also Reduces The Risk of Death The Risk of Death goes down with years of sustained abstinence Users/Early Abstainers more likely to die in the next 12 months It takes 4 or more years of abstinence for risk to get down to community levels Deaths in the next 12 months - (Matched on Gender, Race & Age) Source: Scott, Dennis, Simeone & Funk (forthcoming)

Other factors related to death rates Death is more likely for those who Are older Are engaged in illegal activity Have chronic health conditions Spend a lot of time in hospitals Spend a lot of time in and out of substance abuse treatment Death is less common for those who Have a greater percent of time abstinent Have longer periods of continuous abstinence Get back to treatment sooner after relapse

Recovery Management Checkups (RMC) Quarterly monitoring after treatment Linkage meeting/motivational interviewing to: provide personalized feedback to participants about their substance use and related problems, help the participant recognize the problem and consider returning to treatment, address existing barriers to treatment, and schedule an assessment. Linkage assistance reminder calls and rescheduling Transportation and being escorted as needed Treatment Engagement Specialist

Reducing Time from Relapse to Readmission 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 50% more got back to treatment Time from relapse to readmission reduced by over 50% Percent Readmitted 1+ Times 55% Checkups 37% Control 0% 3 6 9 12 15 18 21 Months From Relapse to Readmission Source: Scott & Dennis (2009)

Positive Consequences of Early Readmission Checkups and Early Readmission to Treatment were associated with: Less substance use and problems Longer periods of abstinence More attendance and engagement in self help activities Above were associated with: Fewer HIV risk behaviours Less illegal activity, arrests, and time incarcerated Fewer mental health problems Less utilization and costs to society Source: Scott & Dennis (2009)

Cost of Substance Abuse Treatment Episode $750 per night in Detox $1,115 per night in hospital $13,000 per week in intensive care for premature baby $27,000 per robbery $67,000 per assault Drug treatment courts - Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban Institute. Health Serv Res. 2006 February; 41(1): 192–213. doi: 10.1111/j.1475-6773.2005.00466.x.PMCID: PMC1681530Copyright © Health Research and Education Trust Benefit–Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment “Pay for Itself”? Susan L Ettner, David Huang, Elizabeth Evans, Danielle Rose Ash, Mary Hardy, Mickel Jourabchi, and Yih-Ing Hser The economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and reimbursement Michael T. French, (Ph.D.)a,b,c,d,⁎, Ioana Popovici, (Ph.D.)d, Lauren Tapsell, (B.A.)d Journal of Substance Abuse Treatment xx (2008) xxx–xxx $22,000 / year to incarcerate an adult $30,000/ child-year in foster care $70,000/year to keep a child in detention Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004

Investing in Treatment has a Positive Annual Return on Investment (ROI) Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested Treatment drug courts have an average ROI of $2.14 to $2.71 per dollar invested This also means that for every dollar treatment is cut, we lose more money than we saved. Drug treatment courts - Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban Institute. Health Serv Res. 2006 February; 41(1): 192–213. doi: 10.1111/j.1475-6773.2005.00466.x.PMCID: PMC1681530Copyright © Health Research and Education Trust Benefit–Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment “Pay for Itself”? Susan L Ettner, David Huang, Elizabeth Evans, Danielle Rose Ash, Mary Hardy, Mickel Jourabchi, and Yih-Ing Hser The economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and reimbursement Michael T. French, (Ph.D.)a,b,c,d,⁎, Ioana Popovici, (Ph.D.)d, Lauren Tapsell, (B.A.)d Journal of Substance Abuse Treatment xx (2008) xxx–xxx Source: Bhati et al., (2008); Ettner et al., (2006)

Summary Points Addiction can be a chronic condition with high costs to the individual and society Getting people to recovery earlier requires getting people to treatment sooner after initial use and after relapse Simple protocols like recovery checkups can help achieve abstinence sooner and improve a wide range of outcomes

Implications for Health Care Reform Finance addiction care similar to models for other chronic conditions Fund programs to get people into treatment early Expand capacity to reduce treatment gap Increase step down and continuing care Increase links to self help and recovery services Require several years of monitoring and early re-intervention when people relapse Financing for addiction care should ideally be modeled after financing for other chronic conditions This means being more assertive in finding and getting people into treatment initially Expanded treatment capacity to reduce demand Improved step down and continuing care Better linkage to self help and recovery services Several years of post treatment monitoring Teaching self management and monitoring Assertive early re-intervention when people relapse

References Bhati et al. (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders.  Washington, DC: Urban Institute. Capriccioso, R. (2004).  Foster care: No cure for mental illness.  Connect for Kids.  Accessed on 6/3/09 from http://www.connectforkids.org/node/571 Chandler, R.K., Fletcher, B.W., Volkow, N.D. (2009).  Treating drug abuse and addiction in the criminal justice system: Improving public health and safety.  Journal American Medical Association, 301(2), 183-190 Dennis, M.L., Foss, M.A., & Scott, C.K (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612 Dennis, M. L., Scott, C. K. (2007). Managing Addiction as a Chronic Condition. Addiction Science & Clinical Practice , 4(1), 45-55. Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment careers. Journal of Substance Abuse Treatment, 28, S51-S62. Ettner, S.L., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., & Hser, Y.I. (2006).  Benefit Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment Pay for Itself?.  Health Services Research, 41(1), 192-213. French, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates of cost bands for program assessment and reimbursement. Journal of Substance Abuse Treatment, 35, 462-469 Neumark, Y.D., Van Etten, M.L., & Anthony, J.C. (2000). Drug dependence and death: Survival analysis of the Baltimore ECA sample from 1981 to 1995. Substance Use and Misuse, 35, 313-327. Office of Applied Studies (2006). Results from the 2005 National Survey on Drug Use and Health: National Findings Rockville, MD:  Substance Abuse and Mental Health Services Administration.  http://www.oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm#7.3.1  Riley, B.B.,, Scott, C.K, & Dennis, M.L. (2008). The effect of recovery management checkups on transitions from substance use to substance abuse treatment and from treatment to recovery.  Poster presented at the UCLA Center for Advancing Longitudinal Drug Abuse Research Annual Conference, August 13-15, 2008, Los Angles, CA.  www.caldar.org . Scott, C. K., & Dennis, M. L. (in press). Results from Two Randomized Clinical Trials evaluating the impact of Quarterly Recovery Management Checkups with Adult Chronic Substance Users. Addiction. Scott, C. K., Dennis, M. L., Simeone, R., & Funk R. (forthcoming). Predicting the likelihood of death of substance users over 9 years based on baseline risk, treatment and duration of abstinence. Chicago, IL: Chestnut Health Systems. Scott, C. K., Foss, M. A., & Dennis, M. L. (2005). Pathways in the relapse, treatment, and recovery cycle over three years. Journal of Substance Abuse Treatment, 28, S61-S70. Volkow N.D., Fowler J.S., Wang G-J., Hitzemann R., Logan J., Schlyer D., Dewey 5., Wolf A.P. (1993). Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177. Volkow, N.D., Hitzemann R., Wang C-I., Fowler I.S., Wolf A.P., Dewey S.L. (1992). Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190.