1. Shifting the Treatment Paradigm to Managing Addiction as a Chronic Condition Michael Dennis, Ph.D. Chestnut Health Systems, Bloomington, IL Presentation at the Haymarket Center's 15th Annual Summer Institute On Addictions, Oakbrook Terrace, IL, June 9-11, 2009.. This presentation was supported by funds from NIDA grants no. R13 DA027269, R01 DA15523, R37-DA11323 and CSAT contract no. 270-07-0191. It is available electronically at www.chestnut.org/li/posters. The opinions are those of the authors do not reflect official positions of the government. Please address comments or questions to the author at mdennis@chestnut.org or 309-820-3805.

2. 2 1.Identify some of the problems with acute care model of treatment 2.Describe the characteristics of chronic care models of treatment 3.Develop strategies for making treatment more consistent with a chronic care model Goals of this Presentation are to

3. 3 Agenda Virtual walk through clinical practice as usual A fearless appraisal of the strengths and weakness of the current systems A review of what we mean by saying substance use disorders are chronic Characteristics of Chronic Care models How we can improve practice in our own programs

4. 4 Virtual walk through clinical practice Call Appointment – Person or voicemail? – Time on hold? – What information collected? Is it Used? – Appointment scheduled right away or after how long? – Time from first contact to appointment? – Limited or Flexible of appointment time? – Implications for work, child care, transportation? – Any common complements or complaints? Facility – Transportation, parking, signage issues? – Institution vs. warm feel, comfort, privacy? – Self contained vs. having to move around? – Any common complements or complaints?

5. 5 Intake – Waiting room comfort, beverage, entertainment, time? – Arrangements for family or friends? – Exams, urine tests, other invasive procedures? – Any information from initial call used/trusted? – Open, rating or standardized assessment? – Objectivity, Consistency and formal rules for diagnosis, placement and treatment planning? – Speed of interpretation & recommendations? – Time to first treatment? – Any intervening services or assistance? – Time and linkage to first treatment plan? – What are the most common recommendations? – Any common complements or complaints? Continued

6. 6 Treatment – Scheduling flexibility – Privacy, comfort, – Once assigned is intake assessment used / trusted or are some or all of the assessment repeated in early treatment? – How well are the actual treatment plan and services linked to assessment? – Is their an orientation or motivational interviewing track everyone goes through in the beginning? – Are there special tracks or phases? – What happens if someone does not show for treatment the first time? Once? More than once? – What happens if someone does not appear to be getting along with their primary counselor? – What happens if someone continues to use? – Any common complements or complaints? Continued

7. 7 Continuing care – How long does treatment usually last for the middle 50%? – How often are people recommended to transfer to another level of care or program? How often do they get there? – How are clients referred to other services? – How is it monitored whether they get them? – Are these referrals passive or assertive? – What happens if they do not show to the other level of care, program or service? – Are there do not readmit lists, why are clients on them and how often does this happen? – How often would you have a least one follow-up with someone 90 or more days after the initial treatment discharge? – Any common complements or complaints? Continued

8. 8 What would change if…. – The person calling in had been in treatment 5 or more times before? – Had been in your program 5 or more times? – Had been in your program 5 or more times in the last 12 months? Do you.. – Monitor whether the services recommended are actually delivered to a manual or clear quality standard beyond simple length of stay or paper work? – Know the most common presenting needs of your clients and have evidenced based approaches to deal with them? – Have formal training protocols for staff on assessment, treatment and other services you routinely provide? – Know the profile of clients that you do well with, do ok with, do badly with? Continued

9. 9 Common Complaints Cold inadequate facilities and lack of privacy Poor staff engagement (vs. customer service) Burdensome procedures and process (e.g., having to wait, answering the same questions to different people, answering questions that did not seem linked to services received, information not being used) Failure to appreciate the complexity and interaction of multiple problems and their implications for what is needed/feasible Arbitrary decisions and consequences Lack of options and administrative discharge of people for confirming their diagnosis

10. 10 Key Problem 1: Current Treatment System is Insufficient Less than 1 in 10 people with abuse/dependence getting to treatment Less than 50% stay 50 days (~7 weeks) Less the 25% stay the 3 months recommended by NIDA researchers Less than half have positive discharges After intensive treatment, less than 10% step down to outpatient care

11. 11 Key Problem 2: Lack of Standardized Assessment for… Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self- mutilation and suicidality) Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime) HIV risk behaviors (needle use, sexual risk, victimization) Child maltreatment (physical, sexual, emotional)

12. 12 Key Problem 3: No or Inconsistent Use of Placement Criteria In practice, programs primarily refer people to the limited range of services they have readily available. Knowing nothing about the person other than what door they walked through we can correctly predict 75% (kappa=.51) of the adolescent level of care placements. The American Society for Addiction Medicine (ASAM) has tried to recommend placement rules for deciding what level of care an adolescent should receive based on expert opinion, but run into many problems.

13. 13 Key Problem 3 (continued): Examples of problems with placement difficulty synthesizing multiple pieces of information inconsistencies between competing rules the lack of the full continuum of care to refer people to having to negotiate with the participant, families and funders over what they will do or pay for there is virtually no actual data on the expected outcomes by level of care to inform decision making related to placement

14. 14 Key Problem 4: Need for Specific Protocols and Services Related to Motivational Interviewing and other protocols to help them understand how their problems are related to their substance use and that they are solvable Need for residential, IOP and other types of structured environments to reduce short term risk of relapse Relapse Prevention Proactive urine monitoring Need for recovery coaches, recovery schools, recovery housing and other adolescent oriented self help groups / services Detoxification services and medication Tobacco cessation

15. 15 Key Problem 4 (continued): Need for Specific Protocols and Services Related to Need for specific protocols related to trauma, suicide ideation, and para-suicidal behavior Need for victimization or child maltreatment interventions (not just reporting protocols) HIV Intervention to reduce high risk pattern of sexual behavior Anger Management Psychiatric services related to depression, anxiety, ADHD, conduct disorder, and ASPD/BPD Work or School problems Family problems

16. 16 Key Problem 5: Need for Tracks, Phases and Continuing Care Over half of adults and a third of adolescents are “returning” to treatment (more than a quarter for the second or more time) We need to understand what did and did not work the last time and have alternative approaches We need tracks or phases that recognize that they may need something different or be frustrated by repeating the same material again and again We need to have better step down and continuing care protocols We need better protocols for linking people to on-going recovery support services

17. 17 Current Paradigm of “Acute Care” Treatment and Research Focus on initial assessment and placement Brief and/or short term single episodes of care focused primarily on substance use, motivation, cognition and coping skills Indirect focus on changing the social recovery environment (with TCs being a major exception) Minimal or no post-discharge check-ups Evaluation of outcomes over relatively short periods of time (6-12 months) with the expectation that improvements should continue after treatment (i.e., an “acute care” model)

18. 18 The Rise of Chronic Conditions From 1900 to 1999 … Medical advances in treating accidents and infectious diseases reduced their likelihood of being the cause of death from over 60% to under 20%. This led to a rise in chronic conditions (e.g., heart disease, diabetes, cancer, respiratory illnesses, Alzheimer's) being the cause of death from under 20% to over 70%. It is estimated that modifiable behaviors caused or exacerbated 48% or more of these chronic conditions This includes 22% who used tobacco, alcohol and other drugs and another 4% who engaged in behaviors that can be substance related (e.g., sexual transmission, motor vehicle, fire arm) Source: Mokdad et al 2004.

19. 19 What do we mean by saying something is a chronic condition? There are often multiple interacting biological, behavioral and environment factors associated with current and future severity The condition lasts over many years There is a large risk of relapse after treatment or initial periods of remission Multiple episodes of care are often required While treatment is typically more effective than no treatment, each episode is associated with a worse prognosis There are some who may require continuous treatment or support for the rest of their lives

20. 20 Need for a Chronic Care Model for Managing Addiction Many consumers and clinicians view substance use as a chronic relapsing condition. An emerging body of evidence from treatment epidemiology suggests that the typical pathway to recovery currently involves multiple episodes of care over many years. Among people admitted to publicly funded treatment reported in TEDS, for instance, 60% of the people had been been in treatment before (including 23% 1x, 13% 2xs, 7% 3xs, 17% 4 or more). There is a high risk of relapse after treatment and the prognosis gets worse with each readmission

21. 21 Normal Cocaine Abuser (10 days) Cocaine Abuser (100 days) Photo courtesy of Nora Volkow, Ph.D. 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. Brain Activity on PET Scan After Using Cocaine With repeated use, there is a cumulative effect of reduced brain activity which requires increasingly more stimulation (i.e., tolerance) Even after 100 days of abstinence activity is still low

22. 22 Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

23. 23 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Using (N=661) 1 to 12 ms (N=232) 1 to 3 yrs (N=127) 3 to 5 yrs (N=65) 5 to 8 yrs (N=77) % Days of Psych Prob (of 30 days) % Above Poverty Line % Days Worked For Pay (of 22) % of Clean and Sober Friends % Days of Illegal Activity (of 30 days ) Other Aspects of Recovery by Duration of Abstinence of 8 Years Source: Dennis, Foss & Scott (2007)

24. 24 Sustained Abstinence Also Reduces The Risk of Death Source: Scott, Dennis, Simeone & Funk (forthcoming) - Users/Early Abstainers more likely to die in the next 12 months The Risk of Death goes down with years of sustained abstinence It takes 4 or more years of abstinence for risk to get down to community levels (Matched on Gender, Race & Age)

25. 25 Customer service and structured/firm but non confrontational Assertive outreach, engagement, continuing care, and follow-up Placement into tracks, phases or services that take into account prior services and the past response to treatment Increased focus on multiple problems, services and systems Increased focus on monitoring adherence and adjusting intervention Use of checkups and early re-intervention Consistent assessment and records over multiple episodes of care Characteristics of Chronic Care Models of Treatment

26. 26 Meta analyses and Implementation Science Suggest that Major Predictors of Bigger Effects are: 1. Used triage to focus on the highest severity subgroup and/or an explicit target group 2. Chose a strong intervention protocol based on prior evidence 3. Used quality assurance to ensure protocol adherence and project implementation 4. Used proactive case supervision of individual

27. 27 Impact of the numbers of Favorable features on Recidivism (509 JJ studies) Source: Adapted from Lipsey, 1997, 2005 Average Practice

28. 28 Crime/Violence and Substance Problems Interact to Predict Recidivism Low Mod. High Low Mod. High 0% 20% 40% 60% 80% 100% Source: CYT & ATM Data 12 month recidivism Crime/ Violence predicted recidivism Substance Problem Severity predicted recidivism Knowing both was the best predictor Substance Problem Scale Crime and Violence Scale

29. 29 Crime/Violence and Substance Problems Interact to Predict Violent Crime or Arrest Low Mod. High Low Mod. High Source: CYT & ATM Data 12 month recidivism To violent crime or arrest Substance Problem Scale Crime and Violence Scale 0% 20% 40% 60% 80% 100% Crime/ Violence predicted violent recidivism (Intake) Substance Problem Severity did not predict violent recidivism Knowing both was the best predictor

30. 30 Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Recidivism (29% vs. 40%) Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving MET/CBT combinations and Other manualized CBT Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ACRA) Assertive Continuing Care Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004 NOTE: There is generally little or no differences in mean effect size between these brand names

31. 31 Implementation is Essential ( Reduction in Recidivism from.50 Control Group Rate) The effect of a well implemented weak program is as big as a strong program implemented poorly The best is to have a strong program implemented well Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

32. 32 Number of Clinical Problems by Level of Care Source: CSAT 2007 AT Outcome Data Set (n=12,824) The Severity of People is NOT the same across levels of care.

33. 33 No. of Problems* by Severity of Victimization Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254) Those with high lifetime levels of victimization have 117 times higher odds of having 5+ major problems* * (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity) Severity of Victimization

34. 34 Recovery* by Level of Care: * 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

35. 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, 2007

36. 36 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

37. 37 ACC Enhancements Continue to participate in UCC Home Visits Sessions for adolescent, parents, and together Sessions based on Adolescent Community Reinforcement Approach (A-CRA) 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)

38. 38 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.

39. 39 ACC Improved Adherence Source: Godley et al 2002, 2007 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

40. 40 GCCA Improved Early (0-3 mon.) Abstinence Source: Godley et al 2002, 2007 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

41. 41 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence Source: Godley et al 2002, 2007 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

42. 42 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 ACC1 main findings are published and findings from two subsequent experiments are currently under review CSAT is currently replicating ACRA/ACC in 32 sites The ACC manual is being distributed via the website and the CD.

43. 43 To further improve the effectiveness of substance abuse treatment, we need to: identify and address the complex array of co-occurring problems that can impede sustained recovery, move beyond a system of passive referrals for co- occurring problems to an integrated and assertive system of care, proactively monitor patients after the traditional points of discharge, help them with long term recovery management, and promote early re-intervention when appropriate, and generally shift the paradigm of clinical models from an acute care approach to models that effectively manage chronic substance use disorders.

44. 44 Policy and Research Implications Change systems of care and financial support mechanisms from acute to chronic care models. Identify the complex clusters of co-occurring problems – both in terms of statistical factors and population subgroups. Develop effective recovery management strategies. Examine treatment effects across episodes of care. Examine the predictors of the trajectories for achieving and sustaining recovery over longer periods of time. Conduct more longitudinal research over the lifespan of the substance use and treatment careers.