Managing Substance Use Disorders (SUDS) as a Chronic Condition

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 August 14, 2006 Presentation at the UCLA Center for Advancing Longitudinal Drug Abuse Research (CALDAR) Summer Institute, “Current Findings and Future Directions in Longitudinal Research Conference”, Los Angeles, CA, August 14-16, 2006. This presentation was supported by funds from CALDAR 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/posters .

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 • Quantifying the patterns that demonstrate that substance use disorders are a chronic condition • Examining the cycle of relapse, treatment, incarceration and recovery that characterize the course of this condition and what predicts transition • Presenting the results of two experiments designed to improve the ways in which this condition is managed across time and multiple episodes of care.

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

5. Adolescent Onset Remission Problems Vary by Age NSDUH Age Groups Increasing rate of non-users 100 Severity Category 90 No Alcohol or Drug Use 80 70 Light Alcohol Use Only 60 Any Infrequent Drug Use 50 40 Regular AOD Use 30 Abuse 20 10 Dependence 0 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Source: 2002 NSDUH and Dennis & Scott under review

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

7. 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).

8. The Majority Stay in Tx Less than 90 days 90 60 52 42 Median Length of Stay in Days 33 30 20 0 Outpatient Intensive Short Term Long Term Outpatient Residential Residential Level of Care 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 .

9. Less Than Half Are Positively Discharged 100% 90% Other 80% 70% Terminated 60% Discharge Status Dropped out 50% 40% Completed 30% 20% Transferred 10% 0% Less than 10% are transferred Outpatient Intensive Short Term Long Term Outpatient Residential Residential Level of Care 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 .

10. Multiple Co-occurring Problems are Correlated with Severity and Contribute to Chronicity Adol. More likely to have externalizing disorders 100% 100% 40% 60% 80% 20% 20% 40% 60% 80% 0% 0% Health Distress Internal Disorders Adults more likely to have internalizing disorders[ External Disorders Crime/Violence Criminal Justice System Involvement Adults Adolescents Exception Dependent (n=1221) Dependent (n=3135) Abuse/Other (n=385) Abuse/Other (n=2617) Source: GAIN Coordinating Center Data Set

11. Pathways to Recovery Study (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. Substance: Cocaine (33%), heroin (31%), alcohol (27%), marijuana (7%). 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

12. Pathways to Recovery Sample Characteristics 100% 20% 40% 60% 80% 0% African American Age 30-49 Female Current CJ Involved Past Year Dependence Prior Treatment Residential Treatment Other Mental Disorders Homeless Physical Health Problems

13. 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

14. Age Distributions Predominately Adolescent onset

15. Substance Use Careers Last for Decades 100% 90% 80% Percent in Recovery 70% Median duration of 27 years (IQR: 18 to 30+) Years from first use to 1+ years abstinence 60% 50% 40% 30% 20% 10% 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

16. Substance Use Careers are Longer, the Younger the Age of First Use 100% 90% 21+ 80% Percent in Recovery 15-20* Age of 1st Use Groups 70% Years from first use to 1+ years abstinence 60% under 15* 50% 40% 30% 20% * p<.05 (different from 21+) 10% 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

17. Substance Use Careers are Shorter the Sooner People get to Treatment 100% 0-9* 90% 80% 10-19* Years to 1st Tx Groups Percent in Recovery 70% Years from first use to 1+ years abstinence 60% 50% 40% 20+ 30% 20% 10% * p<.05 (different from 20+) 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

18. It Takes Decades and Multiple Episodes of Treatment 100% 90% 80% Percent in Recovery 70% Median duration of 9 years (IQR: 3 to 23) and 3 to 4 episodes of care Years from first Tx to 1+ years abstinence 60% 50% 40% 30% 20% 10% 0% 0 5 10 15 20 25 Source: Dennis et al 2005 (n=1,271)

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

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

21. Predictors of Change Also Vary by Direction • 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) In the 13% In Recovery Community (58% stable) Using 29% (53% stable) 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) Source: Scott et al 2005

22. 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.

23. The Early Re-Intervention (ERI) Experiments (Dennis & Scott) Funding Source NIDA grant R37-DA11323

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

25. 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… During the past 90 days, have you used alcohol, marijuana, cocaine, or other drugs on 13 or more days? During the past 90 days, have you gotten drunk or been high for most of 1 or more days? 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? During the past week, had withdrawal symptoms when you tried to stop, cut down, or control your use? Do you feel that you need to return to treatment? During the past month, has your substance use caused you any problems? Note alpha > .90

26. 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

27. Modifications to RMC for ERI -2 included: • Switch to from off- to on-site urine monitoring with immediate feedback on results (before detailed questions) to allow to probing and improve identification • 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

28. ERI 1 False Negative Rates High and Going Up ERI 2 False Negative Rates Lower and Going Down False Negative Rates by Time and Experiment 50% Any Drug Tested Reported Any AOD Reported \b Any AOD or Medication Reported \c 40% 30% 19% 20% 15% 15% 9% 9% 10% 5% 4% 3% 3% 2% 1% 1% 0% 12 Months 24 Months 12 Months 24 Months ERI 1 (n=350) ERI 1 (n=313) ERI 2 (n=424) ERI 2 (n=424) \a False negative defined as positive on the substance(s) but reporting no use in the past month \b Considers self report of above plus alcohol,hallucinogens, PCP, other psychotopics, inhalants, and other drugs \c Any of the above or any prescribed medication related to substance use, mental health or physicial health treatment

29. Quality assurance and transportation assistance reduced the variance Generally averaged as well or better ImprovedScreening Improved Tx Engagement RMC Protocol Adherence Rate by Experiment 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Treatment Need (30 vs. 44%) d=0.31* Follow-up Interview (93 vs. 96%) d=0.18* Showed to Assessment (30 vs. 42%) d=0.26* Showed to Treatment (25 vs. 30%) d=0.18* Agreed to Assessment (44 vs. 45%) d=0.02 Linkage Attendance (75 vs. 99%) d=1.45* Treatment Engagement (39 vs. 58%) d=0.43* ERI-1 ERI-2 <-Average-> Range of rates by quarter * P(H: RMC1=RMC2)<.05

30. 630-403 = -200 days ERI-1 Time to Treatment Re-Entry 100% 90% 80% 70% (n=221) 60% ERI-1 RMC* Percent Readmitted 1+ Times 60% 51% ERI-1 OM (n=224) 50% 40% 30% Revisions to the protocol 20% *Cohen's d=+0.21 10% Wilcoxon-Gehen 0% Statistic (df=1) 630 270 360 450 540 180 90 0 =2.78, p <.05 Days to Re-Admission (from 3 month interview)

31. 100% The size of the effect is growing every quarter 90% 80% 70% 630-246 = -384 days 60% 50% 40% 30% 20% 10% 0% 630 270 360 450 540 180 90 0 ERI-2 Time to Treatment Re-Entry Percent Readmitted 1+ Times (n=221) 55% ERI-2 RMC* 37% ERI-2 OM (n=224) *Cohen's d=+0.41 Wilcoxon-Gehen Statistic (df=1) =18.86, p <.0001 Days to Re-Admission (from 3 month interview)

32. No effect on Abstinence/Symptoms ERI-1: Impact on Outcomes Months 4-24 Final Interview 100% RMC 90% OM 80% 79% 79% 79% RMC Broke the Run 80% Less Likely to be in Need of Treatment 70% 56% 60% Percentage 50% 43% 40% 26% 30% 21% 21% 21% 20% 10% 0% of 630 Days of 7 Subsequent of 90 Days of 11 Sx of Still in need of Tx Abstinent Quarters in Need Abstinent Abuse/Dependence (d=0.00) (d= -0.15) * (d= -0.05) (d=0.01) (d= -0.30) * * p<.05

33. Significant Increase in Abstinence ERI-2: Impact on Outcomes Months 4-24 Final Interview 100% RMC 90% OM RMC Broke the Run 76% 75% 80% Less Likely to be in Need of Treatment 68% 67% 70% 60% 54% Less Symptoms Percentage 46% 50% 42% 35% 40% 28% 30% 19% 20% 10% 0% of 630 Days of 7 Subsequent of 90 Days of 11 Sx of Still in need of Tx Abstinent Quarters in Need Abstinent Abuse/Dependence (d=0.29)* (d= -0.29) * (d= 0.23)* (d= -0.23)* (d= -0.29) * * p<.05

34. Status at the end of Quarter In the community In Recovery In Treatment In the community using Status at beginning of Quarter As expected, 32% of individuals change status between the beginning and end of the quarter (82% over 2 years) End of Quarter 100% 90% 80% 70% 60% 50% 40% 30% 20% Incarcerated 10% 0% Recovery Inc. In Tx. In the Community Using (42%) (5%) (12%) (41%) (3,136 quarterly transition Observations on 448 unique people) Beginning of Quarter

35. Again the Probability of Entering Recovery is Higher from Treatment Impact on Primary Pathways to Recovery (incarceration not shown) • 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) 17% 18% In the Community y In Recovery Using (76% stable) (71% stable) 27% 8% 33% 5% • Transition to Tx • Freq. of Use (0.7) • + Prob. Orient. (1.4) • + Desire for Help (1.6) • + RMC (3.22) In Treatment (35% stable) Source: ERI experiments (Scott, Dennis, & Foss, 2005)

36. 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

37. 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 identification, showing to treatment, and engagement for at least 14 days upon readmission helped to improve outcomes

38. These studies provide converging evidence demonstrating that • substance use disorders are often chronic in the sense that they last for years and the risk of relapse is high • the majority of people accessing publicly funded substance abuse treatment have been in treatment before, are likely to return, have a variety of co-occurring problems and may need several additional episodes of care before they reach a point of stable recovery. • Yet over half do make it to recovery and the odds of getting to and staying in recovery can be improved with proactive management.

39. 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

40. Other Emerging Recovery Support Initiatives • Assertive Continuing Care (ACC; http://www.chestnut.org/li/apss/CSAT/protocols/ ) • 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/ ) • Washington Circle Group (http://www.washingtoncircle.org/) and other efforts to introduce performance monitoring

41. 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. • GAIN Coordinating Center Data Set (2005). Bloomington, IL: Chestnut Health Systems. See 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. • 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 . • 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.