1. 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 and several other authors/studies. It is available electronically at 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 or .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

2. 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

3. 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: , 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: , 1993.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. What does recovery look like on average?
Duration of Abstinence
1-12 Months Years 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)

12. 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)

13. 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

14. 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

15. 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)

16. 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)

17. 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 February; 41(1): 192–213. doi: /j x.PMCID: PMC Copyright © 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

18. 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 February; 41(1): 192–213. doi: /j x.PMCID: PMC Copyright © 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)

19. 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

20. 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

21. 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
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),
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),
Dennis, M. L., Scott, C. K. (2007). Managing Addiction as a Chronic Condition. Addiction Science & Clinical Practice , 4(1),
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),
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,
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 Substance Use and Misuse, 35,
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. 
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.  .
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:
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: