1. 1 Managing Substance Use Disorders (SUDS) as a Chronic Condition Michael L. Dennis, Ph.D. Chestnut Health Systems 720 W. Chestnut, Bloomington, IL 61701, USA E-mail: mdennis@chestnut.org Presentation in the Recovery Conference: Vision to Outcomes Hartford, CT, May 16-17, 2006 This presentation was supported by funds from the Connecticut Department of Mental Health and Addiction Services and data from NIDA grant no. R37-DA11323, and R01 DA15523 and SAMHSA/CSAT contract no. 270-2003-00006. The opinions are those of the author do not reflect official positions of the government. Please address comments or questions to the author at mdennis@chestnut.org or 309-820-3805. A copy of these slides will be posted at www.chestnut.org/li/postersmdennis@chestnut.orgwww.chestnut.org/li/posters.

2. 2 Problem and Purpose Over the past several decades there has been a growing recognition that a subset of substance users suffers from a chronic condition that requires multiple episodes of care over several years. This presentation will focus on 1.Describing the prevalence and characteristics of this subset of people 2.the course of these disorders, and 3.the results of three experiments designed to improve the ways in which this condition is managed across time and multiple episodes of care.

3. 3 Definition of Chronic SUD While terms like substance use, abuse, dependence, and addiction are frequently used interchangeably, state regulators, accreditation programs, clinical providers and more recently clinical researchers have become increasingly consistent in how they define chronic substance use disorders. The American Psychiatric Association (APA, 1994, 2000) and the World Health Organization (WHO, 1999) use the term “substance dependence” to indicate a pattern of chronic problems (e.g., withdrawal, inability to stop, giving up activities) that are likely to persist. They use the term “substance abuse” and “hazardous use” respectively to identify people not meeting the dependence criteria but having other moderate severity symptoms (e.g., hazardous use, legal problems) suggesting the need for treatment. These standards also recognize that the course of substance use disorders includes periods of relapse, treatment, incarceration, and remission (i.e., the absence of symptoms while in the community)

4. 4 Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246) Dependence 5% Abuse 4% Regular AOD Use 8% Any Infrequent Drug Use 4% Light Alcohol Use Only 47% No Alcohol or Drug Use 32% Source: 2002 NSDUH and Dennis & Scott under review

5. 5 Problems Vary by Age Source: 2002 NSDUH and Dennis & Scott under review 0 10 20 30 40 50 60 70 80 90 100 12-1314-1516-1718-2021-2930-3435-4950-64 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 Increasing rate of non- users

6. 6 Higher Severity is Associated with Higher Annual Cost to Society Per Person Source: 2002 NSDUH and Dennis & Scott under review $0 $231 $725 $406 $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence Median (50 th percentile) $948 $1,613 $1,078 $1,309 $1,528 $3,058 Mean (95% CI) This includes people who are in recovery, elderly, or do not use because of health problems Higher Costs

7. 7 Age of First Use Predicts Symptoms of Dependence an Average of 22 years Later Source: Dennis, Babor, Roebuck & Donaldson (2002) and 1998 NHSDA 39 45 63 71 37 34 51 62 30 23 41 48 0 10 20 30 40 50 60 70 80 90 100 Tobacco, OR=1.3*, Pop.=151,442,082 Alcohol, OR=1.9*, Pop.=176,188,916 Marijuana, OR=1.5*, Pop.=71,704,012 Other, OR=1.5*, Pop.=38,997,916 % with 1+ Past Year Symptoms Under Age 15 Aged 15-17 Aged 18 or older Tobacco: Pop.=151,442,082 OR=1.49* Alcohol: Pop.=176,188,916 OR=2.74* * p<.05 Marijuana: Pop.=71,704,012 OR=2.45* Other Drugs: Pop.=38,997,916 OR=2.65*

8. 8 Study 2. Pathways to Recovery (Scott & Dennis) Recruitment: 1995 to 1997 Sample: 1,326 participants from sequential admissions to a stratified sample of 22 treatment units in 12 facilities, administered by 10 agencies on Chicago's west side. Levels of Care: Adult OP, IOP, MTP, HH, STR, LTR Instrument:Augmented version of the Addiction Severity Index (A-ASI) Follow-up:Of those alive and due, follow-up interviews were completed with 94 to 98% in annual interviews out to 8 years (going to 10 years); over 80% completed within +/- 1 week of target date. Funding: CSAT grant # T100664, contract # 270-97-7011 NIDA grant 1R01 DA15523

9. 9 Intake Characteristics Participants were mostly African-American (88%), female (59%), and in their 30s (48%); At intake, 32% were homeless and 25% were involved in the criminal justice system. The most common substances used weekly were: cocaine (33%), heroin (31%), alcohol (27%), and marijuana (7%). Many met criteria for Major Depression (36%) or Generalized Anxiety Disorder (36%). 54% have been in treatment before (27% 2+ times) The participants were initially referred to outpatient (19%), methadone (19%), intensive outpatient (18%), halfway house (10%), short term residential (20%), long term residential (13%).

10. 10 Survival Analysis Time frames related to age of use, treatment, and death were measured across all sources and waves of information (taking the earliest first use, treatment episode, and 12 month period of abstinence or death). Age at last use was defined as the age when a person first completed a period of 12 month abstinence or had died (35 or 2.6% of the people died in 3 years). Durations were estimated with Cox Proportional Hazards Regression –censoring people who were in treatment or still using, –censoring years past which we had less than 100 people to make the estimate, and –creating a 30 year window of observation on the trajectory of substance use disorders starting at the time of first use

11. 11 Age Distributions

12. 12 Substance Use Careers Last for Decades Percent in Recovery Years from first use to 1+ years abstinence 302520151050 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Median duration of 27 years (IQR: 18 to 30+) Source: Dennis et al 2005 (n=1,271)

13. 13 Substance Use Careers are Longer, the Younger the Age of First Use Percent in Recovery Years from first use to 1+ years abstinence 302520151050 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Dennis et al 2005 (n=1,271) under 15* 21+ 15-20* Age of 1 st Use Groups * p<.05 (different from 21+)

14. 14 Substance Use Careers are Shorter the Sooner People get to Treatment Percent in Recovery Years from first use to 1+ years abstinence 302520151050 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Dennis et al 2005 (n=1,271) 20+ 0-9* 10-19* Years to 1 st Tx Groups * p<.05 (different from 20+)

15. 15 It Takes Decades and Multiple Episodes of Treatment Years from first Tx to 1+ years abstinence 2520151050 Median duration of 9 years (IQR: 3 to 23) and 3 to 4 episodes of care Percent in Recovery 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Dennis et al 2005 (n=1,271)

16. 16 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Over 55% Continued to Changed Status Between Annual Follow-up Interviews (83% over 3 years) In the community In Recovery In Treatment Incarcerated In the community using In the Community Using (57%) Inc. (6%) Recovery (26%) In Tx. (12%) Status at 24 months Status at 36 months

17. 17 The Cyclical Course of Relapse, Incarceration, Treatment and Recovery In the Community Using (53% stable) In Treatment (21% stable) In Recovery (58% stable) Incarcerated (37% stable) 6% 13% 28% 30% 8% 25% 31% 4% 44% 7% 29% 7% Treatment is the most likely path to recovery P not the same in both directions Source: Scott et al 2005

18. 18 Source: Scott et al 2005 Predictors of Change Also Vary by Direction In the Community Using (53% stable) In Recovery (58% stable) 13% 29% Probability of Relapsing from Abstinence + times in treatment (1.21) - female (0.58) + homelessness (1.64)- number of arrests (1.12) - ASI legal composite (0.84) - # of sober friend (0.82) - per 77 self help sessions (1.41) Probability of Transitioning from Using to Abstinence - mental distress (0.88)+ older at first use (1.12) -ASI legal composite (0.84) + homelessness (1.27) + # of sober friend (1.23) + per 8 weeks in treatment (1.14)

19. 19 Post Script on the Pathways Study There is clearly a subset of people for whom substance use disorders are a chronic condition that last for many years Rather than a single transition, most people cycle through abstinence, relapse, incarceration and treatment 3 to 4 times before reaching a sustained recovery. It is possible to predict the likelihood risk of when people will transition Treatment predicts who transitions from use to recovery and self help group participation predicts who stays in recovery.

20. 20 Treatment Participation Only 1 in 5 people with dependence or abuse in the U.S. receive any kind of treatment, and about half of those access it through publicly-funded substance abuse treatment (Epstein, 2002) People presenting to publicly funded treatment with dependence (vs. others with abuse, intoxication, primarily other psychiatric diagnoses) are more likely to have been –in treatment before one or more times (57% vs. 39%, OR=1.46, p<.05), –in treatment 3 or more times (16% vs. 9%, OR=1.79, p<.05), –assigned to intensive outpatient (15% vs. 6%, OR=2.52, p<.05) –assigned to residential treatment (16% vs. 5%, OR=3.17, p<.05) (OAS, 2002 on line data at http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00056.xml) People with 3 or more diagnoses were significantly more likely than those with just 1 diagnosis to enter treatment (34% vs. 7%) (Kessler, et al., 1996).

21. 21 The Majority Stay in Tx Less than 90 days Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf. 52 42 20 33 0 30 60 90 OutpatientIntensive Outpatient Short Term Residential Long Term Residential Level of Care Median Length of Stay in Days

22. 22 Less Than Half Are Positively Discharged Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX, UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% OutpatientIntensive Outpatient Short Term Residential Long Term Residential Level of Care Discharge Status Other Terminated Dropped out Completed Transferred Less than 10% are transferred

23. 23 Number of GAIN Sites Adolescent and Adult Treatment Program GAIN Clinical Collaborators 30 to 60 10 to 29 2 to 9 1 One or more state or county wide systems uses the GAIN One or more state or county wide systems considering using the GAIN 07/05

24. 24 Multiple Co-occurring Problems Contribute to Chronicity 0% 20%40%60%80% 100% Health Distress Internal Disorders External Disorders Crime/Violence Criminal Justice System Involvement Dependent (n=1221) Other (n=385) 0% 20% 40%60%80% 100% Dependent (n=3135) Other (n=2617) Adolescents Adults Source: GAIN Coordinating Center Data Set Exception

25. 25 Treatment Outcomes by Level of Care: Recovery* * Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT Adolescent Treatment Outcome Data Set (n-9,276) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pre-IntakeMon 1-3Mon 4-6Mon 7-9Mon 10-12 Percent in Past Month Recovery* Outpatient (+79%, -1%) Residential(+143%, +17%) Post Corr/Res (+220%, +18%) OP & Resid Similar CC better

26. 26 Findings from the Assertive Continuing Care (ACC) Experiment 183 adolescents admitted to residential substance abuse treatment Treated for 30-90 days inpatient, then discharged to outpatient treatment Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC) Over 90% follow-up 3, 6, & 9 months post discharge Source: Godley et al 2002, in press

27. 27 Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17) Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0102030405060708090 Days after Residential (capped at 90) Percent of Clients Cont. Care Admis. Relapse

28. 28 ACC Enhancements Continue to participate in UCC Home Visits Sessions for adolescent, parents, and together Sessions based on ACRA manual (Godley, Meyers et al., 2001) Case Management based on ACC manual (Godley et al, 2001) to assist with other issues (e.g., job finding, medication evaluation)

29. 29 Assertive Continuing Care (ACC) Hypotheses Assertive Continuin g Care General Continuin g Care Adherence Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA) Early Abstinence GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence Sustained Abstinence Early abstinence will be associated with higher rates of long term abstinence.

30. 30 ACC Improved Adherence Source: Godley et al 2002, forthcoming 0% 10% 20% 30% 40%50%60%70%80% WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/probation/school Follow up on referrals* ACC * p<.05 90% 100% Relapse prevention* Communication skills training* Problem solving component* Meet with parents 1-2x month* Weekly telephone contact* Referrals to other services* Discuss probation/school compliance* Adherence: Meets 7/12 criteria* UCC

31. 31 GCCA Improved Early (0-3 mon.) Abstinence Source: Godley et al 2002, forthcoming 24% 36% 38% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=2.16*)Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA 43% 55% High (7-12/12) GCCA * p<.05

32. 32 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence Source: Godley et al 2002, forthcoming 19% 22% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=11.16*)Alcohol (OR=5.47*) Marijuana (OR=11.15*) Early(0-3 mon.) Relapse 69% 59% 73% Early (0-3 mon.) Abstainer * p<.05

33. 33 Post script on ACC The ACC intervention improved adolescent adherence to the continuing care expectations of both residential and outpatient staff; doing so improved the rates of short term abstinence and, consequently, long term abstinence. Despite these gains, many adolescents in ACC (and more in UCC) did not adhere to continuing care plans. The ACC preliminary findings are published and the main findings are currently under review. Several CSAT grantees are also seeking to replicate ACC as part of the Adolescent Residential Treatment (ART) and Assertive Adolescent Family Therapy (AAFT) programs. A second ACC experiment is currently under way to evaluate whether providing contingency management will further improve outcomes. The ACC manual is being distributed via the website and the CD you have been provided.

34. 34 The Early Re-Intervention (ERI) Experiments ERI 1ERI 2 RecruitmentRecruited 448 from Community Based Treatment in Chicago in 2000 (84% of eligible recruited) Recruited 446 from Community Based Treatment in Chicago in 2004 (93% of eligible recruited) DesignRandom assignment to Recovery Management Checkups (RMC) or control Follow-UpQuarterly for 2 years (95- 97% per wave) Quarterly for 4 years (95 to 97% per wave) Data SourcesGAIN, CEST, Urine, Salvia Staff logs GAIN, CEST, CAI, Neo, CRI, Urine, Staff logs PublicationDennis, Scott & Funk 2003; Scott, Dennis & Foss, 2005 Scott & Dennis, under review (12 month findings) Funding Source NIDA grant R37-DA11323

35. 35 Sample Characteristics of ERI 1 & 2 Experiments 0% 20%40%60%80% 100% African American Age 30-49 Female Employed Dependence Prior Treatment Residential Treatment Other Mental Disorders Homeless Physical Health Problems ERI 1 (n=448) ERI 2 (n=446)

36. 36 Need For Treatment Re-Intervention Eligibility: Not already in treatment or incarcerated and living in the community Need: Yes to at least one of the following… (a)During the past 90 days, have you used alcohol, marijuana, cocaine, or other drugs on 13 or more days? (b)During the past 90 days, have you gotten drunk or been high for most of 1 or more days? (c)During the past 90 days, has your alcohol or drug use caused you not to meet your responsibilities at work/school/home on 1 or more days? (d)During the past week, had withdrawal symptoms when you tried to stop, cut down, or control your use? (e)Do you feel that you need to return to treatment? (f)During the past month, has your substance use caused you any problems?

37. 37 Recovery Management Checkups (RMC) in both ERI 1 & 2 included: Quarterly Screening to determining “Eligibility” and “Need” 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

38. 38 720630540450360270180900 1.0.9.8.7.6.5.4.3.2.1 0.0 H1: RMC Clients will return to treatment sooner Control (51% readmitted) Days to Readmission Percent to be Readmitted OR: 1.34 X 2 (1) =6.8, p<.01 RMC (64% readmitted) Median of 376 vs. 600 days, Wald=5.2, p<.05

39. 39 H2: RMC clients will receive more treatment Days % with 90+ Days 50 0 10 20 30 40 50 60 70 Control RMCMean Days of Subsequent Treatment (months 4-24) t (390) =2.65, p<.05 17% 62 25% 0% 5% 10% 15% 20% 25% 30% Control RMC % with 90+ days of Subsequent Treatment (months 4-24) OR 1.61, X 2 (1) =4.1, p<.05

40. 40 H3: RMC clients will be less likely to use at 24m 43% 56% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Control (n=244)RMC (n=224) X 2 (1) = 7.7, p<.01

41. 41 However, 32% of individuals change status between the beginning and end of the quarter (82% over two years) In the community In Recovery In Treatment Incarcerated In the community using In the Community Using (41%) Inc. (5%) Recovery (42%) In Tx. (12%) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% End of Quarter Beginning of Quarter (3,136 quarterly transition Observations on 448 unique people) Status at beginning of Quarter Status at the end of Quarter

42. 42 Source: ERI experiments (Scott, Dennis, & Foss, 2005) Impact on Primary Pathways to Recovery (incarceration not shown) In the Communityy Using (71% stable) In Treatment (35% stable) In Recovery (76% stable) 27% 5% 8% 33% 18% 17% Transition to Tx - Freq. of Use (0.7) + Prob. Orient. (1.4) + Desire for Help (1.6) + RMC (3.22) Again the Probability of Entering Recovery is Higher from Treatment Transition to Recov. - Freq. of Use (0.7) - Dep/Abs Prob (0.7) - Recovery Env. (0.8) - Access Barriers (0.8) + Prob. Orient. (1.3) + Self Efficacy (1.2) + Self Help Hist (1.2) + per 10 wks Tx (1.2)

43. 43 Other Variables That Lost Significance in Multivariate Model Problem Recognition, External Pressure, Internal Motivation, Treatment Resistance Current Withdrawal, Number of Diagnosis, Emotional Problems, Illegal Activity, Homelessness Coming from a controlled environment Involvement with the Criminal Justice System, Mental Health, Health, or Training/School Systems Lifetime number of prior treatment, arrests Gender, Race, Age, Employment

44. 44 Modifications to RMC for ERI -2 included: Switch to on-site urine monitoring with immediate feedback to improve detection Transportation assistance for everyone to improve the show rates for assessment and treatment Improved Quality Assurance/Adherence Engagement assistance to improve the rates of staying at least 14 days –Daily contact (mostly face to face) –Acting as an ombudsman –Agreement from provider not to administratively discharge from treatment without contacting us first

45. 45 0% 20% 40% 60% 80% 100% Follow-up (96% avg) Needed Tx (45% avg) Attended Linkage (99% avg) Agreed to Tx Assessment (48% avg) Showed to Tx Assessment (42% avg) Showed to Tx (35% avg) Stayed in Tx 14+ days (60% avg) ERI 1 Max Avg Min Adherence to Recovery Management Checkup (RMC) Protocol in ERI 1 vs. 2 Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis, forthcoming) Generally averaged as well or better Quality assurance and transportation assistance reduced the variance Improved Screening ERI 2 Improved Retention

46. 46 % Readmitted (Months 4-12) Relative to Control clients, RMC clients were more likely to return to treatment Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scot & Dennis, forthcoming 30% 38% 22% 36% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% ERI 1 (d=+.17)TERI-2 (d=+.30)* 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% *p<.05 ERI 1 RMCERI 2 ControlERI 2 RMCERI 1 Control

47. 47 Mean Days of Treatment Received (months 4-12) RMC clients received more Total Days of Treatment Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming) ERI 1 RMCERI 2 ControlERI 2 RMCERI 1 Control

48. 48 % with any successive quarters in need of treatment RMC clients were less likely to have Successive Quarters in Need of Treatment Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming) ERI 1 RMCERI 2 ControlERI 2 RMCERI 1 Control

49. 49 In Need of Tx (using in community) at 12 months RMC clients were less likely to be in need of treatment at the end of 12 months Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming) Every Quarter this difference has been growing; Hence our plans to go out 4 years ERI 1 RMCERI 2 ControlERI 2 RMCERI 1 Control

50. 50 Post Script on ERI experiments Again, severity was inversely related to returning to treatment on your own and treatment was the key predictor of transitioning to recovery The ERI experiments demonstrate that the cycle of relapse, treatment re-entry and recovery can be shortened through more proactive intervention Working to ensure engagement for at least 14 days upon readmission helped to improve outcomes

51. 51 Other Emerging Recovery Support Initiatives Interactive phone and web based monitoring and recovery support Self help groups Recovery homes Recovery High Schools & Colleges Well-briety movement in Indian Country Recovery advocacy movement Network for the Improvement of Addiction Treatment (NIATx; http://www.pathstorecovery.org/http://www.pathstorecovery.org/ Washington Circle Group (http://www.washingtoncircle.org/) and other efforts to introduce performance monitoringhttp://www.washingtoncircle.org/

52. 52 Reprise These studies provide converging evidence demonstrating that substance use disorders commonly present with a wide range of co-occurring problems that are likely to interfere with recovery. They show that the majority of people accessing publicly funded substance abuse treatment have been in treatment before, are likely to return, and may need several additional episodes of care before they reach a point of stable recovery. Yet over half do make it to recovery The three experiments demonstrated that it is feasible to alter the substance use trajectories and treatment careers.

53. 53 We need to.. Educate policy makers, staff and clients to have more realistic expectations Redefine the continuum of care to include monitoring and other proactive interventions between primary episodes of care. Shift our focus from intake matching to on-going monitoring, matching over time, and strategies that take the cycle into account Identify other venues (e.g., jails, emergency rooms) where recovery management can be initiated Evaluate the costs and determine generalizability to other populations through replication Explore changes in funding, licensure and accreditation to accommodate and encourage above

54. 54 Sources and Related Work American Psychiatric Association. (1994). American Psychiatric Association diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR) (4th - text revision ed.). Washington, DC: American Psychiatric Association. Epstein, J. F. (2002). Substance dependence, abuse and treatment: Findings from the 2000 National Household Survey on Drug Abuse (NHSDA Series A-16, DHHS Publication No. SMA 02-3642). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Retrieved from http://www.DrugAbuseStatistics.SAMHSA.gov.http://www.DrugAbuseStatistics.SAMHSA.gov GAIN Coordinating Center Data Set (2005). Bloomington, IL: Chestnut Health Systems. See www.chestnut.org/li/gain.www.chestnut.org/li/gain Kessler, R. C., Nelson, G. B., McGonagle, K. A., Edlund, M. J., Frank, R. G., & Leaf, P. J. (1996). The epidemiology of co- occurring mental disorders and substance use disorders in the national comorbidity survey: Implications for prevention and services utilization. Journal of Orthopsychiatry, 66, 17-31. Dennis, M. L., Scott, C. K. (under review). Managing substance use disorders (SUD) as a chronic condition. NIDA Science and Perspectives. 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. Dennis, M. L., Scott, C. K., & Funk, R. (2003). An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. Evaluation and Program Planning, 26(3), 339-352. Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. (2002). Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment, 23, 21-32. Office Applied Studies (2002). Analysis of the 2002 National Survey on Drug Use and Health (NSDUH) on line at http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00064.xml. http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00064.xml Office Applied Studies (2002). Analysis of the 2002 Treatment Episode Data Set (TEDS) on line data at http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00056.xml) Scott, C. K., & Dennis, M. L. (forthcoming). A Replicable Model for Managing Addiction as a Chronic Condition using Quarterly Recovery Management Check-ups (RMC). Manuscript under review. Scott, C. K., Dennis, M. L., & Foss, M. A. (2005). Utilizing recovery management checkups to shorten the cycle of relapse, treatment re-entry, and recovery. Drug and Alcohol Dependence, 78, 325-338. 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. World Health Organization (WHO). (1999). The International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10). Geneva, Switzerland: World Health Organization. Retrieved from www.who.int/whosis/icd10/index.html. www.who.int/whosis/icd10/index.html