1. 1 Understanding and Managing Addiction as a Chronic Condition Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation at the Pacific Asia Judges Science and Technology Seminar, November 10-12, 2010, Hyatt Regency Hotel, Tumon, Guam. This presentation was supported by funds from and data from NIDA grants no. R01 DA15523, R37-DA11323, R01 DA021174, and CSAT contract no. 270- 07-0191. It is available electronically at www.chestnut.org/li/posters. The opinions are those of the author do not reflect official positions of the government. Please address comments or questions to the author at Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761www.chestnut.org/li/posters mdennis@chestnut.org or 309-451-7801.mdennis@chestnut.org

2. 2 The Goals of this Presentation are to: 1.Illustrate the chronic nature of substance use disorders 2.Examine the likelihood and nature of sustained recovery 3.Demonstrate the feasibility of using simple protocols like recovery checkups to improve long-term outcomes

3. 3 Brain Activity on PET Scan After Using Cocaine Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and baboon brain in vivo. Fowler JS, Volkow ND, Wolf AP, Dewey SL, Schlyer DJ, Macgregor RIR, Hitzemann R, Logan J, Bendreim B, Gatley ST. et al. Synapse 1989;4(4):371-377. Rapid rise in brain activity after taking cocaine Actually ends up lower than they started

4. 4 Normal 10 days of abstinence 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. Prolonged Substance Use Injures The Brain: Healing Takes Time Normal levels of brain activity in PET scans show up in yellow to red After 100 days of abstinence, we can see brain activity “starting” to recover Reduced brain activity after regular use can be seen even after 10 days of abstinence

5. 5 Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front

6. 6 Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20 Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000 0 10 20 30 40 50 60 70 80 90 100 12-1314-1516-1718-2021-2930-3435-4950-64 65+ Other drug or heavy alcohol use in the past year Alcohol or Drug Use (AOD) Abuse or Dependence in the past year Age Severity Category Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Percentage People with drug dependence die an average of 22.5 years sooner than those without a diagnosis

7. 7 Yet Recovery is likely and better than average compared with other Mental Health Diagnoses Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication 15% 13% 8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD Alcohol Drug Any Externalizing Conduct Oppositional Defiant Intermittent Explosive Attention Deficit Any Internalizing Anxiety : Mood : Posttraumatic Stress Lifetime Diagnosis 10% 7% Past Year Recovery (no past year symptoms) 66% 77% 83% Recovery Rate (% Recovery / % Dependent) 25% 10% 8% 46% 31% 7% 20% 15% 8%9% 4% 18% 12% 11% 3% 4% 58% 89% 45% 50% 39% 56% 48% 40% SUD Remission Rates are BETTER than many other DSM Diagnoses Median of 8 to 9 years in recovery

8. 8 People Entering Publicly Funded Treatment Generally Use For Decades P e r c e n t s t i l l u s i n g Years from first use to 1+ years of abstinence 302520151050 Source: Dennis et al., 2005 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% It takes 27 years before half reach 1 or more years of abstinence or die

9. 9 Percent still using Years from first use to 1+ years of abstinence under 15* 21+ 15-20 Age of First Use 302520151050 Source: Dennis et al., 2005 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 60% longer The Younger They Start, The Longer They Use * p<.05

10. 10 Percent still using Years from first use to 1+ years of abstinence Years to first Treatment Admission* 302520151050 Source: Dennis et al., 2005 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20 or more years 0 to 9 years 10 to 19 years 57% quicker The Sooner They Get To Treatment, The Quicker They Get To Abstinence * p<.05

11. 11 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

12. 12 * p<.05 The Likelihood of Sustaining Abstinence Another Year Grows Over Time 36% 66% 86% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 to 12 months1 to 3 years4 to 7 years Duration of Abstinence* % Sustaining Abstinence Another Year. After 1 to 3 years of abstinence, 2/3rds will make it another year After 4 years of abstinence, about 86% will make it another year Source: Dennis, Foss & Scott (2007) Only a third of people with 1 to 12 months of abstinence will sustain it another year But even after 7 years of abstinence, about 14% relapse each year

13. 13 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 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 Virtual elimination of illegal activity and illegal income Better housing and living situations Increasing employment and income 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

14. 14 Sustained Abstinence Also Reduces The Risk of Death* Source: Scott, Dennis, Laudet, Funk & Simeone (in press) - 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) Deaths in the next 12 months * p<.05

15. 15 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 and out of 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 Source: Scott, Dennis, Laudet, Funk & Simeone (in press)

16. 16 The Cyclical Course of Relapse, Incarceration, Treatment and Recovery (Pathway Adults) In the Community Using (53% stable) In Treatment (21% stable) In Recovery (58% stable) Incarcerated (37% stable) 6% 28% 13% 30% 8% 25% 31% 4% 44% 7% 29% 7% Treatment is the most likely path to recovery P not the same in both directions Over half change status annually Source: Scott, Dennis, & Foss (2005)

17. 17 Source: Scott, Dennis, & Foss (2005) Predictors of Change Also Vary by Direction In the Community Using (53% stable) In Recovery (58% stable) 28% 29% Probability of Sustaining Abstinence - times in treatment (0.83) + Female (1.72) - homelessness (0.61)+ ASI legal composite (1.19) - number of arrests (0.89)+ # of sober friend (1.22) + per 77 self help sessions (1.82) 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)

18. 18 Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 Cost of Substance Abuse Treatment Episode $22,000 / year to incarcerate an adult $30,000/ child-year in foster care $70,000/year to keep a child in detention $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

19. 19 Investing in Treatment has a Positive Annual Return on Investment (ROI)2 Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested Even the long term and more intensive Treatment Drug Courts programs have an average ROI of $2.14 to $2.71 per dollar invested Source: Bhati et al., (2008); Ettner et al., (2006) This also means that for every dollar treatment is cut, we lose more money than we saved.

20. 20 Early Re-Intervention (ERI) Experiment and Hypotheses Source: Dennis et al 2003, 2007; Scott et al 2005, in press Monitoring and Early Re- Intervention Reduce Time to Re- admission Relative to Control, RMC will reduce the time from relapse to readmission Less Successive Quarters Using The quicker the return to treatment, the less successive quarters using in the community Less Risk Behaviors, MH and Crime The less quarters using in the community, the less HIV Risk Behaviors, Mental Health and Crime Problems

21. 21 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

22. 22 ERI-2 Time to Treatment Re-Entry at Year 4 Percent Readmitted 1+ Times Wilcoxon-Gehen statistic (df=1) = 28.60, p<.001 OR=3.1, p<.05 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0369121518212427303336394245 Months from 1st Follow-up In Need for Treatment, Time from relapse to readmission reduce by 78% (45-13 = -32 months; d=-.41) 74% ERI-2 RMC* (n=198) 48% ERI-2 OM (n=195) RMC increases the odds of re-entering treatment over 4 years by 3.1 Source: Scott & Dennis (2009); Dennis & Scott (under review) The size of the effect grew every quarter

23. 23 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); Dennis & Scott (under review)

24. 24 In the Community Using (71% stable) In Treatment (35% stable) In Recovery (76% stable) Incarcerated (60% stable) 3% 18% 8% 15% 9% 16% 27% 4% 33% 5% 17% 2% 32% Changed Status in an Average Quarter Again the Probability of Entering Recovery is Higher from Treatment Source: Scott et al 2005, Dennis & Scott, 2007 ERI 1: Impact on Primary Quarterly Pathways to Recovery over 2 years

25. 25 In the Community Using (71% stable) Transition to Tx vs. Continued Use - Freq. of Use (0.7) + Prob. Orient. (1.4) + Desire for Help (1.6) + RMC (3.22) 8% In Treatment (35% stable) 18% Transition to Recovery vs Continued Use - Freq. of Use (0.7) + Prob. Orient. (1.3) - Dep/Abs Prob (0.7) + Self Efficacy (1.2) - Recovery Env. (0.8) + Self Help Hist (1.2) - Access Barriers (0.8) + per 10 wks Tx (1.2) In Recovery (76% stable) Source: Scott et al 2005, Dennis & Scott, 2007 ERI 1: Impact on Primary Quarterly Pathways to Recovery over 2 years

26. 26 Adolescents: Also Have Complex Pathways to Recovery In the Community Using (60% stable) In Treatment (45% stable) In Recovery (61% stable) Incarcerated (41% stable) Source: 2009 CSAT AT data set; unique n = 11,710 Avg of 48% change status each quarter 18% 16% 22% 17% 27% 14% 17% 24% 21% 9 % 4%4% 4%4% Treatment is the most likely path to recovery What predicts who enters and maintains recovery?

27. 27 Risk and Protective Factors Associated with Transitioning to/Remaining in Recovery Risk Factors –Older –Male –Caucasian –Substance Problems Substance Frequency –Repeated Treatment –Emotional Problems –Illegal Activity –Employment Protective Factors –Younger –Female –Racial Minority –Recent Treatment –Number of drug screens –Attend 12 Step Meetings –Positive Social Peers –Positive Recovery Environment –School Attendance/ Conduct Source: 2009 CSAT AT data set; unique n = 11,710

28. 28 Cumulative Recovery Pattern 30 Months After Intake Source: Godley et al 2004 37% Sustained Problems 5% Sustained Recovery 19% Intermittent, currently in recovery 39% Intermittent, currently not in recovery The Majority of Adolescents Cycle in and out of Recovery (n=600 adolescents)

29. 29 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

30. 30 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

31. 31 Source: Godley et al 2002, 2007 Assertive Continuing Care (ACC) Experiment (n=183) and 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.

32. 32 Assertive Continuing Care (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) Source: Godley et al 2002, 2007

33. 33 General Continuing Care Adherence (GCCA) 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

34. 34 Adherence 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

35. 35 Opportunities to Better Support Recovery Evidenced Based Recovery Services for Adolescents (1-2 Clinical Trials) Telephone Counseling Assertive Continuing Care Contingency Managements Recovery Coaches or Mentors Other Promising Recovery Services Alcohol/Drug Test Monitoring Self Help Participation Community Reinforcement Approach Family Training (CRAFT) Recovery School Recovery oriented support via technology (ie text, email, social networking, skype)

36. 36 Summary Points Addiction can be a chronic condition with high costs to the individual and society Getting people to sustained 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

37. 37 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., Coleman, V., Scott, C.K & Funk, R (forthcoming). The Prevalence of Remission from Major Mental Health Disorder in the US: Findings from the National Co morbidity Study Replication. 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. 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. 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.www.caldar.org Rush, B., Dennis, M.L., Scott, C.K, Castel, S., & Funk, R.R. (2008). The Interaction of Co-Occurring Mental Disorders and Recovery Management Checkups on Treatment Participation and Recovery. Scott, C. K., & Dennis, M. L. (2009). 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., & 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., Dennis, M. L., & Funk, R.R. (2008). Predicting the relative risk of death over 9 years based on treatment completion and duration of abstinence. Poster 119 at the College of Problems on Drug Dependence (CPDD) Annual Meeting, San Juan, PR, June 16, 2008. Available at www.chestnut.org/li/posters. 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 ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. (1993). Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177. Volkow, ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. (1992). Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190.