Addiction is a chronic disease and it matters Richard A. Rawson, Ph.D, Professor Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine University of California at Los Angeles Supported by: National Institute on Drug Abuse (NIDA) National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) Pacific Southwest Technology Transfer Center (SAMHSA) International Network of Treatment and Rehabilitation Resource Centres (UNODC)

Is Addiction a Chronic Disease?

Demonization Criminalization Psychiatric views Socialization Medicalization Addiction Paradigms Sinful/Immoral Criminal/Illegal Mental Disorder- DSM Learned Behavior/Habit Acute (Brain) Disease Neuro-Science & Longitudinal Research Chronic Illness Leshner, 2001; Anglin et al., 1997

Addiction is a Brain Disease: Implications for Treatment and Recovery

Neuroscience Supports Addiction = Chronic Health Problem …with biological, sociological and psychological components

Why Do People Try Drugs? Curiosity Availability Peer Pressure To have fun Gain Energy Lose Weight Reduce Pain

Why Do People Like Drugs? To feel good To have novel: Feelings Sensations Experiences AND To share them To feel better To lessen: Anxiety Worries Fears Depression Hopelessness Withdrawal

In other words: A Major Reason People Take a Drug is they Like What It Does to Their Brains In other words: A Major Reason People Take a Drug is they Like What It Does to Their Brains

Pathway for Understanding Addictive Effects of Drugs on the Brain & Behavior Reward Pathway

Gray Matter Deficits in Cortex PM Thompson et al., J. Neurosci., 2004

Gray Matter Deficit in Prefrontal Cortex PM Thompson et al., J. Neurosci. 2004

Time (min) % of Basal DA Output NAc shell Empty Box Feeding Source: Di Chiara et al. FOOD Natural Rewards Elevate Dopamine in the Brain

hr Time After Amphetamine % of Basal Release DA DOPAC HVA Accumbens AMPHETAMINE hr Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE hr Time After Morphine % of Basal Release Accumbens Dose (mg/kg) MORPHINE hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE Drugs Also Bring Reward (via Dopamine)

Behavioral Responses How Drugs Work  Loss of control  Continued compulsive use despite harmful use despite harmful consequences consequences  Multiple relapses preceding stable preceding stable recovery recovery

What have we learned through Positron Emission Tomography (PET)?

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

Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp , October 15, Decreased dopamine transporter binding in METH users resembles that in Parkinson ’ s Disease Control Meth PD

Partial Recovery of Dopamine Transporters After Prolonged Abstinence Normal Control Meth user (1 month abstinent) Meth user (36 months abstinent) Why is Continued Treatment Critical?

California Civil Addict Program Follow-up  A cohort of 581 male heroin addicts admitted to the California Civil Addict Program (CAP) in has been followed-up and interviewed over more than 30 years.  The CAP was the only major publicly-funded drug treatment program available in California in the 1960s.  The CAP provided a combination of inpatient and outpatient drug treatment to narcotics-dependent criminal offenders committed under court order.

22% 48% 6% 2% 4% 7% 12% Methadone Maintenance Natural History of Narcotics Addiction Among CAP Sample (N=581)

Status of Respondents at 3 Interview Points Status of Respondents at 3 Interview Points

Causes of Death Among CAP Sample (N = 271) a Includes overdose, poisoning, drug dependence, and suicide by drugs b Includes motor vehicle, suicide, firearms, homicide, and falls c Includes alcoholic cirrhosis, alcohol dependence, and poisoning by alcohol d Includes kidney disease, diabetes, GI, and epilepsy seizures e Includes viral hepatitis, AIDS, TB, and staphylococol depticemia a b c d e

Conclusions  The study findings show the long-term effects of heroin addiction in terms of morbidity, mortality, criminal justice system involvement, and overall level of functioning.  Compared to a US Population sample, heroin addiction reduces life expectancy by an average of 18 years.

Other Long-term Outcome Studies  Alcohol: Vaillant: multiple studies reporting a majority of alcoholics who enter treatment experience multiple relapses and retreatments with about 30-50% achieving stable abstinence.  Cocaine; Hser: Ten year follow-up of cocaine dependent patients in treatment indicates that fewer than 50% achieve extended periods of abstinence. Most reenter treatment multiple times.  Methamphetamine: Marinelli-Casey 3 year follow up indicates of a cohort of 600 MA dependent individuals about 50% continue to use MA at a moderate or severe level during the 3 year post treatment 36 month period.

Re-Addiction Following Prison Re-Addiction Following Prison Vaillant 447 opiate addicts91% Maddux & Desmond 594 opiate addicts 98% Nurco & Hanlon 355 opiate addicts 88% Hanlon & Nurco 237 mixed addicts 70% Many Other Studies Including: (Simpson, Wexler, Inciardi, Hubbard, Anglin) Treatment Research Institute

Acute vs Chronic Treatment

An Acute Model of Treatment vs Chronic Model of Treatment

Drug Abuse Treatment Core Components and Comprehensive Services Mental Health Vocational Educational Legal AIDS / HIV Risks Financial Housing & Transportation Child Care Family Continuing Care Case Management Urine Monitoring Self-Help (AA/NA) Pharmaco- therapy Group/Individual Counseling Abstinence Based Intake Assessment Treatment Plans CoreTreatment Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB) Medical

Treatment Services Continuing Care/Aftercare Programs Intensive Outpatient/Psychosoci al Behavioral Treatment Sober Living Residence Long-term Residential Treatment Short- term Residenti al Treatment Detox/ Inpatient Detox/ Outpatient Medication Assisted Treatment

Public Expectations of Substance Abuse Interventions Public Expectations of Substance Abuse Interventions  Safe, complete detoxification  Reduced use of medical services  Eliminate crime  Return to employment/self support  Eliminate family disruption  No return to drug use

How Do We Think About Treatment?  “The 28 day cure”  Put them in a box, something happens and they come out fixed.  The washing machine model: Put a “dirty addict” in, run the washer, and take out a “clean citizen”.

A Nice Simple Treatment Model Treatment Addicted Patient Non- Addicted Patient

Does the “Washing Machine” Model of Treatment Make Sense?

A Chronic Care Model Detox Continuing Care Recovering Patient Rehab Duration Determined by Performance Criteria Duration Determined by Performance Criteria

Stages of Treatment 1. Treatment Engagement Detoxification/Stabilization Purposes: Safe/Adequate reduction of withdrawal symptoms Physical/Emotional stabilization Promote problem recognition Engage patient into rehabilitation

Stages of Treatment 2. Rehabilitation Purposes: Sustain stable abstinence Teach self-management skills Identify & reduce threats to progress Medications (maintenance and relapse prevention) Engage patient in continuing care

Stages of Treatment 3. Continuing Care Purposes: Monitor & Support Abstinence Encourage Self-Monitoring Intervene Upon Threats to Relapse Promote Participation in Long Term Support Activities

Effective Strategies During Treatment Engagement  Medications  Motivational Interviewing  Voucher-based Techniques  Counseling to Promote Transfer to Long Term Care  NIATx Strategies

Effective Strategies in Rehabilitation Phase  Therapies Cognitive Behavioral Cognitive Behavioral Motivational Enhancement Treatment Motivational Enhancement Treatment Behavioral Couples Therapy Behavioral Couples Therapy Multi Systemic Family Therapy Multi Systemic Family Therapy 12-Step Facilitation 12-Step Facilitation Individual Drug Counseling Individual Drug Counseling

Effective Strategies in Rehabilitation Phase  Interventions/Services Clinical Case Management Clinical Case Management CRAFT CRAFT 12-Step Facilitation 12-Step Facilitation Voucher Reinforcement Voucher Reinforcement Matrix Model Treatment Matrix Model Treatment  Medications Alcohol (Naltrexone, Disulfiram, Citalopram) Alcohol (Naltrexone, Disulfiram, Citalopram) Opiates (Naltrexone, Methadone, Buprenorphine) Opiates (Naltrexone, Methadone, Buprenorphine)

A Chronic Care Model Detox Continuing Care Recovering Patient Rehab Duration Determined by Performance Criteria Duration Determined by Performance Criteria

Types of Continuing Care  Self/mutual help programs  Medications  Traditional counseling visits  Home visits  Recovery “check-ups” Specialty care-based Specialty care-based Primary care-based Primary care-based  Telephone-based protocols Monitoring Monitoring Monitoring and counseling Monitoring and counseling  Other stuff

Recovery Management Checkups  Protocol developed by Dennis, Scott et al. Interview patients every quarter for 2 years Interview patients every quarter for 2 years If patient reports any of the following…… If patient reports any of the following…… Use of alcohol or drugs on > 2 weeksUse of alcohol or drugs on > 2 weeks Being drunk or high all day on any daysBeing drunk or high all day on any days Alcohol/drug use led to not meeting responsibilitiesAlcohol/drug use led to not meeting responsibilities Alcohol/drug use caused other problemsAlcohol/drug use caused other problems Withdrawal symptomsWithdrawal symptoms …Patient transferred to linkage manager …Patient transferred to linkage manager

Recovery Management Checkups  Linkage Manager provides the following: Personalized feedback Personalized feedback Explore possibility of returning to treatment Explore possibility of returning to treatment Address barriers to returning to treatment Address barriers to returning to treatment Schedule an intake assessment Schedule an intake assessment Reminder cards, transportation, and escort to intake appointment Reminder cards, transportation, and escort to intake appointment

Telephone as a continuing care tool  Potential to promote better long-term engagement and participation because: Convenient for client Convenient for client Reduces stigma of weekly trips to the treatment program Reduces stigma of weekly trips to the treatment program Individualized attention Individualized attention Can be automated (Helzer, Searles et al.) Can be automated (Helzer, Searles et al.) Lower costs of ongoing care (?) Lower costs of ongoing care (?)

Evidence Supporting Therapeutic Use of the Telephone  Studies suggest the telephone can be effective in delivering treatment: Addiction (Foote & Erfurt, 1991) Addiction (Foote & Erfurt, 1991) Smoking (Lichtenstein et al., 1996) Smoking (Lichtenstein et al., 1996) Depression (Baer et al., 1995; Simon et al., 2004) Depression (Baer et al., 1995; Simon et al., 2004) OCD (Greist et al., 1998) OCD (Greist et al., 1998) Panic and Anxiety (Rollman et al., 2005) Panic and Anxiety (Rollman et al., 2005) Bulimia (Hugo et al., 1999) Bulimia (Hugo et al., 1999) Cardiac care (Jerant et al., 2001; Riegel et al., 2002) Cardiac care (Jerant et al., 2001; Riegel et al., 2002)

A Continuum of Care Hospital Detox Residential Rehab IOP Care Outpatient Cont Care AA -Tele Monitoring Tele Monitoring

Elements of Continuum of Services Prevention Treatment/Intervention Recovery Services Otpt Tx Detox Intensive Otpt Tx Long-term Res Care Short-term Res Care Methadone Maintenance NTP Detox Recovery

County Profile Samples County A Admissions 50% 20% 25% 9% Number of transfers within the past 30-days following tx discharge

County Profile Samples County B Admissions 20% 40% 75% 7% Number of transfers within the past 30-days following tx discharge

Recovery Services Prevention Treatment/Intervention Recovery Telephone Continuing Care Recovery Coaches/ Centers Recovery Services Otpt Tx Detox Intensive Otpt Tx Long-term Res Care Short-term Res Care Methadone Maintenance NTP Detox

Considerations with the Continuum  Sober housing plus outpatient care vs residential treatment  Integration of medication (including methadone) into the continuum  Determining when to transfer levels of care  Remember, sometimes treatment intensity needs to be increased, not just decreased

Do you really use the full continuum of care?  If you work in a residential treatment program, when was the last time, you referred a client into an intensive outpatient program (other than your own) after they completed residential care?  If you work in an NTP, when was the last time you ever referred a patient into a residential treatment program, if they were doing poorly on methadone?  If you work in an outpatient treatment program, when was the last time you ever put one of your relapsing opiate addicts on buprenorphine, while they were in your outpatient program?

Lessons from Chronic Illness: 1.Medications and discussions of feelings can relieve symptoms but…. behavioral change is necessary for sustained benefit

Lessons from Chronic Illness: Lessons from Chronic Illness: 2. Treatment effects usually don’t last very long after treatment stops.

Lessons from Chronic Illness: Lessons from Chronic Illness: 3. Patients who are not in some form of treatment or monitoring are at elevated risk for relapse.

 Multiple Episodes of Acute Care IS NOT Chronic Care  Patient Retention is Critical  Monitoring in Treatment is Essential Lessons from Chronic Illness:

Medical Detoxification Treatment Programs  Medical Detoxification is a treatment service used to systematically withdraw individuals from a substance in an inpatient or outpatient setting.  Treatment is provided under the care of a medical doctor.  Detoxification is a short treatment and does not address the psychosocial and behavioral issues linked to addiction.  Detoxification is most valuable when it encompasses formal processes of assessment and results with a referral to successive substance abuse treatment. Detox/ Inpatient Detox/ Outpatient

Inpatient Residential Treatment  Short-term Residential Treatment (commonly referred to as the Minnesota Model) focuses on the introduction to the 12 Step Program and long term participation in 12 Step programs for recovery support.  Long-term Residential Treatment (often referred to as the modified Therapeutic Community approach) involves an extended period (3-12 months) of living within a highly structured recovery community. “Treatment” is delivered via peer interactions within the community.  Sober Living Residence is a living environment that has supervision and a recovery environment. It should be used in conjunction with outpatient treatment and is not considered “treatment” on its own Sober Living Residence Long-term Residential Treatment Short-term Residential Treatment

Intensive Outpatient Treatment  Outpatient Treatment varies in length of stay, but typically lasts at least 90 days and is followed by outpatient continuing care.  Patients generally receive 6 to 30 contact hours per week. Core services include: group, individual and family counseling, psychoeducation, relapse prevention training, positive reinforcement techniques; family involvement; urine and breath alcohol testing; 12 Step (or alternative) participation; case management; medication, vocational and educational services. Core services include: group, individual and family counseling, psychoeducation, relapse prevention training, positive reinforcement techniques; family involvement; urine and breath alcohol testing; 12 Step (or alternative) participation; case management; medication, vocational and educational services. Intensive Outpatient/Psychosocial Behavioral Treatment

Medication Assisted Treatment  Medication (e.g. Methadone, Buprenorphine) provided in phases by a certified, licensed Opioid Treatment Program (OTP) or a through a trained medical doctor.  Medication Assisted treatment provides maintenance pharmacotherapy using an opioid agonist, a partial agonist, or an antagonist medication.  The medication may be combined with other treatment services, including medical and psychosocial services. Medication Assisted Treatment

Effective Programs  Longer duration (2-4 years).  Higher doses, > 60mg methadone.  Accessible prescriber and dispenser.  Ancillary services.  Quality of therapeutic relationship.

What is Treatment? Buprenorphine  A new opiate pharmacotherapy  Can be used for opiate withdrawal or maintenance  Can deliver from MD offices, not necessarily NTPs  Medication is very safe, produces less dependence than methadone (withdrawal easier)  Partial agonist, blocks other opiates  May not be potent enough for heavy, long time users  Diversion is possible, but preventable.

Treatment Episode Detox/ Outpatient Medication Assisted Treatment

Treatment Episode Continuing Care/Aftercare Programs Sober Living Residence Intensive Outpatient/Psychosoci al Behavioral Treatment Long-term Residential Treatment

Treatment Episode Continuing Care/Aftercare Programs Detox/ Inpatient Long-term Residential Treatment Intensive Outpatient/Psychosoci al Behavioral Treatment Sober Living Residence

The Red Arrow – Transfer/Referral Strategies for enhancing treatment service linkage: Case management process Integrating staff from different treatment levels Create a personal linkage Transportation to facility Referral in appropriate geographical location

Measuring Program Performance: A Key to a Successful Continuum of Care Program Performance: What is it and how will we measure it?

Measuring Program Performance Definition: AOD treatment program performance is evaluated by measuring the extent to which the clients of a treatment program achieve specific benchmarks. In California, the key to this measurement will be the data collected in CalOMS

How will CalOMS be used to improve program performance?  CalOMS data collection system that gives policymakers the ability to measure the performance of AOD programs.  The CalOMS data can be used to: 1. monitor treatment program performance 1. monitor treatment program performance 2. improve the management of treatment services. 2. improve the management of treatment services. 3. establish performance benchmarks 3. establish performance benchmarks 4. recognize better/poorer performing programs. 4. recognize better/poorer performing programs. 5. rewarding performance of better performing programs and targeting technical assistance to struggling programs. 5. rewarding performance of better performing programs and targeting technical assistance to struggling programs.

How do we measure the performance of California’s treatment system?

A Source of Confusion: Outcomes vs Performance  Outcomes: OUTCOME MEASURES ARE USED AT THE PATIENT LEVEL AND MEASURE CHANGES IN PATIENT BEHAVIOR OR FUNCTIONING OVER TIME  Performance: PERFORMANCE MEASURES ARE USED AT THE TREATMENT PROGRAM LEVEL TO EXAMINE THE FUNCTIONING OF THE TREATMENT PROGRAM

Treatment Initiation/Engagement Definitions: Initiation: Do people who enter treatment receive at least 2 treatment visits in the first 2 weeks? Engagement: Do people who enter treatment receive at least 4 sessions in the first 30 days/  Meaningful: Yes  Clearly Defined: Yes  Reliability and Validity of Measures: Yes  Readily Accessible Data for Measures: ????

Treatment Retention Definition:  Retention: Number of days between admission and discharge.  Meaningful: Yes  Clearly Defined: Yes  Reliability and Validity of Measures: Yes (maybe)  Readily Accessible Data for Measures: Yes

Continuity of Care Definition:  Do individuals who enter treatment proceed through multiple service sets (levels of care)  Meaningful: Yes  Clearly Defined: Yes  Reliability and Validity of Measures: Yes  Readily Accessible Data for Measures: Yes

Treatment Episode Continuing Care/Aftercare Programs Sober Living Residence Intensive Outpatient/Psychosoci al Behavioral Treatment Long-term Residential Treatment

Treatment Completion Definition: Per CALOMS discharge, do people complete treatment  Meaningful: Yes  Clearly Defined: No  Reliability and Validity of Measures: No  Readily Accessible Data for Measures: Yes

Other Discharge Categories Definitions: Leave with Satisfactory Progress?: Do people who enter treatment and leave before completion make satisfactory progress? Leave with Unsatisfactory Progress?: Do people who enter treatment and leave before completion have unsatisfactory progress  Meaningful: ??  Clearly Defined: No  Reliability and Validity of Measures: No  Readily Accessible Data for Measures: Yes

Strategies for improving AOD program performance  Reduce staff turnover  Increase staff knowledge of other forms of care to promote a “system of care” rather than isolated programs  Increase staff knowledge and use of evidence-based practices  Employ process improvement (NIATx)

A Continuing Care “System” of AOD Treatment is more than a “Bunch of Programs”

Inpatient Detox Short-term Residential Care Long-term Residential Care Current Publicly Funded Services Residential Facilities Outpatient Services Narcotic Treatment Program Brief Treatment Outpatient Treatment Intensive Outpatient Treatment Outpatient Detox Methadone Maintenance

Sober Living Facilities Elements of Treatment System Not Currently Funded Sober Living Facilities Addiction Physicians Continuing Care Services Medication Assisted Treatment for Opiate Addiction: Suboxone, Naltrexone Recovery Centers Recovery Check-ups Medication Assisted Treatment for Alcohol Abuse and Dependence: Vivatrol, Acamprosate, Ondansetron Telephone Support Services

Geographic Distribution of Services, __________ County, CA NTP RS OP NTP AP SL AP SL Client’s house

Geographic Distribution of Services, __________ County, CA NTP RS OP NTP AP SL AP SL Client’s house

Some Requirements of a “System” of Care  Individuals are treated with the most appropriate, evidence-based treatment approaches and in the appropriate level of care.  Workforce recognizes the benefits of all evidence based treatment approaches and attempts to place individuals in most effective form of care.  Workforce is informed and knowledgeable about treatment services delivered by other treatment organizations in the service area.

Some Requirements of a “System” of Care  Clients will be transferred along the continuum of care with communication and cooperation (“warm referral”)between treatment organizations.  Performance data will be collected and used by County Administration and by treatment providers to monitor progress toward a Continuing Care System of AOD treatment.  Performance data must not add substantial data burden to service providers and data must be given to providers in a timely manner and in a form that is clear and meaningful.

A word about data quality… Newer Measures for a System of Care

Fresno CalOMS Data from 2008

Tx Modality No. of Admissions Fresno 26% 11% 9% 20% 32%

Tx Modality No. of Admissions State 29% 11% 13% 21% 30%

Destination Treatment Type Fresno Detox Total: 1078 *Transfers to NTP Detox = 0, Day Care Rehab = 1 State Detox Total: *Transfers to NTP Detox = 4, Day Care Rehab = 71, Maintenance= 126 Transfers from Detox

Destination Treatment Type *Transfers to NTP Detox = 2, Maintenance= 1 *Transfers to NTP Detox = 46, Maintenance= 98 Residential Total: 41,636 Residential Total: 2154FresnoState Transfers from Residential

Mean No. of Days in Tx Drug Category *Other = barbiturates, PCP, inhalants, ecstasy, hallucinogens, club drugs, and other stimulants and tranquilizers

Mean No. of Days in Tx Type of Tx Modality

Building Interactive Service Systems  To create a treatment system that produces the best outcomes for patients, it is necessary for AOD services within a county to be delivered in a “system of care” rather than a “bunch of isolated programs”. it is necessary for AOD services within a county to be delivered in a “system of care” rather than a “bunch of isolated programs”.

Thank You