Treating Addiction as a chronic disease

1. Treating Addiction as a chronic disease John F. Kelly, Ph.D. Elizabeth R. Spallin Associate Professor of Psychiatry in Addiction Medicine Harvard Medical School Director Recovery Research Institute MGH Center for Addiction Medicine Faxton St. Lukes, October 17th 2014

2. Disclosure of Relevant Financial Relationships Content of Activity: Faxton St. Lukes Talk Date of Activity: Octobr 17th 2014

3. Recovery Research Institute LaunchOctober 30, 2013www.recoveryanswers.org www.recoveryanswers.org

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8. Health care is changing and SUD is (Finally) becoming an important focus in that change

10. Definitions, terminology, stigma and discrimination • Should we use the term “Chronic disease”? • Or, “alcohol/drug problem? • Or call it “substance abuse/abuser”? • Does it really matter what we call it or them? • Is it chronic? Is it a “disease”?

11. What is a “disease”? “adisordered or incorrectly functioning organ, part,  structure, or system of the body resulting from the effect of genetic or developmental errors, infection,  poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors.” – Dictionary.com “ a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms” -Miriam Webster It matters, because the words we use influence our conceptualizations and approaches to it (e.g., “War on drugs” “You use you lose” vs addiction as a public health problem)

12. “Chronic”?Who (2014) • “Noncommunicablediseases (NCDs), also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression. The four main types of noncommunicable diseases are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.”

13. Not all those who meet criteria for SUD have chronic trajectories…Epidemiologist’s illusion vs. clinician's illusion Age Groups 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 NSDUH and Dennis & Scott

14. Remission of Dependence Is Common, but for Some Individuals’ Dependence Can Span Decades High remission rates But for some, chronic, harmful course… Source: NIAAA 2001-2002 NESARC data (18-60+ years of age) and SAMHSA 2003 NSDUH (12-17 years of age).

15. Subtypes – but identification of clinically meaningful subtypes challenging…Typology Investigations Silkworth (1939) Jellinek (1960) Cloninger (1981) Babor (1992) Del Boca (1994) Del Boca (1996) Hesselbrock (2006) Moss (2007) Anton (2008)

16. For more severely dependent individuals … course is chronic but remission most likely outcome Addiction Onset Help Seeking Full Sustained Remission (1 year abstinent) RelapseRisk drops below 15% 4-5 years 5 years 8 years 60% of individuals with addiction will achieve full sustained remission (White, 2013) 4-5 Treatment episodes/ mutual-help Self-initiated cessation attempts Continuing care/ mutual-help Opportunity for earlier detection through screening in non-specialty settings like primary care/ED

17. Addiction is heavily stigmatized and the language we use may affect stigma/discrimination

18. Language surrounding clinical care in addiction is unlike any other area of medicine - may affect quality and effectiveness of care • A patient suffering from diabetes has “an elevated glucose”. A patient with cardiovascular disease has “a positive exercise tolerance test” • Someone inside the healthcare system addresses the results. • An “addict” isn’t “clean”—he has been “abusing” drugs and has a “dirty” urine. • Someone outside the system that cares for all other health conditions addresses the results. • In the worst case, the drug use is addressed by incarceration.

19. SUD Stigma/Discrimination moderated by two factors… • CAUSE • Did they cause it? • “It’s not their fault” (decreases stigma; increase compassion) • CONTROLLABILITY • Can they help it? • “They can’t help it” (decreases stigma; increases compassion)

20. Two commonly used terms… • Referring to someone as… • “a substance abuser” – implies perpetration/willful misconduct (they CAN help it) • “having a substance use disorder” – implies victim/medical malfunction (they CAN’T help it)

22. How we talk and write about these conditions and individuals suffering them does matter

23. Doctoral-level clinicians (n=561) randomized to receive one of two terms…. Mr. Williams is a substance abuser and is attending a treatment program through the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been doing extremely well, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has been a substance abuser for the past six years. He now awaits his appointment with the judge to determine his status. Mr. Williams has a substance use disorder and is attending a treatment program through the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been doing extremely well, until one month ago, when he was found to have two positive urine toxicology screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past month there was a further urine toxicology screen revealing drug use. Mr. Williams has had a substance use disorder for the past six years. He now awaits his appointment with the judge to determine his status.

24. Figure 1. Subscales comparing the “substance abuser” and “substance use disorder” descriptive labels Kelly, JF, Dow, SJ, Westerhoff, C. Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms (2010) Journal of Drug Issues

25. Implications • Exposure to the “abuser” term may activate an implicit more punitive cognitive bias • Learn from our friends in other fields : • Individuals with “eating related problems” are uniformly described as “having an eating disorder” NEVER as “food abusers”

26. Stop talking “dirty”: clinicians, language, and quality of care for the leading cause of preventable death in the United StatesKelly, JF, Wakeman, SE, Saitz, R. American journal of medicine (in press) • Avoid stigmatizing terminology such as “dirty” vs “clean” utox screens, instead of “negative/positive”. • Recommendations: • Use “person first” language - refer to individuals with addiction as people with a “substance use disorder” not as substance “abusers” or “addicts.” • For those with consequences or risk, but not a disorder (often referred to inaccurately as “abuse”), use “hazardous”, “risky”, or “harmful” use, or for the full spectrum that includes risk to a disorder, “unhealthy” use. • …commit to a medically appropriate lexicon which conveys the same dignity and respect we offer to other individuals suffering from an array of medical problems.

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28. For more severely dependent individuals course of addiction is chronic … Addiction Onset Help Seeking Full Sustained Remission (1 year abstinent) RelapseRisk drops below 15% 4-5 years 5 years 8 years 60% of individuals with addiction will achieve full sustained remission (White, 2013) 4-5 Treatment episodes/ mutual-help Self-initiated cessation attempts Continuing care/ mutual-help Opportunity for earlier detection through screening in non-specialty settings like primary care/ED

29. But, What if REALLY Believed Addiction was a Chronic Disorder? • If really believed addiction is chronic we would not: • View prior tx failure as a poor prognostic indicator • Convey the expectation that all clients should achieve complete, enduring sobriety following single, brief treatment episode • Punitively d/c clients for becoming symptomatic/confirming their diagnosis • Relegate continuing care to an afterthought • Terminate the service relationship following acute care • Treat serious and persistent SUD in serial episodes of self-contained and unlinked interventions White and Kelly (2011)

30. Chronic nature of substance dependence makes it well-suited to ongoing Recovery Management (RM) approaches… Addiction talked as chronic but still treated as acute condition: Recovery management is a philosophy of organizing addiction treatment and recovery support services to enhance early pre-recovery engagement, recovery initiation, long-termrecovery maintenance…(White & Kelly, 2011).

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32. Why do people have a hard time staying sober and in remission? Addiction is a… • A disease of the brain that affects the neuro-circuitry of reward, memory, motivation, impulse control, and judgment • For recovery to occur, accurate risk appraisals must be conducted and frequent adaptive decisions made and actions taken (prefrontal cortex) to inhibit impulses and gradually correct dysregulated reward system (limbic system) • Rewards of use are immediate, concentrated, predictable; rewards of recovery are delayed, diffuse, and variable • Recovery is a demanding, effortful, process requiring constant vigilance to protect against the risk of relapse and can lead to frustration and exhaustion…

33. Why do people have a hard time staying sober and in remission? • General Adaptation Syndrome (Selye, 1956) • Alarm – Resistance – Exhaustion • “… after self-control efforts, subsequent attempts at self-control are more likely to fail. Continuous self-control efforts, such as vigilance, also degrade over time…These decrements appear to be specific to behaviors that involve self-control(Muraven & Baumeister, 2000). • Post-acute withdrawal and need to learn complex recovery coping skills – stressful; taxes available coping resources - affects relapse risk • Need to find ways to replenish cognitive resources to inhibit thoughts and impulses to use substances over time…

34. In fact, the recovery construct, like the addiction construct, is made up of two reciprocal factors: “remission” and the consequences of that remission, “recovery capital”; as longer remission is achieved, more capital accrues, BUT also, remission can be influenced the other way - as more recovery capital accrues so the chances of continued remission increase. Kelly and Hoeppner (2014) A biaxial formulation of the recovery construct, Addiction Research and Theory

35. Decrease stress and replenish coping resources by providing RM and Recovery Support Services

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37. Clinically, we’ve learned that prized-based CM approaches can produce large effects while contingencies in place …. But advantage disappears by 6m once removed

38. Examples of Long-term recovery management programs • Physicians Health Programs • Hawaii Opportunity Probation with Enforcement (HOPE) • South Dakota “24/7” • Clinical Recovery Management Check-ups • Mutual-help organizations

39. Physicians Health Programs • Emerged in 1970s, through the American Medical Association to help alcohol/drug impaired physicians • Services provided include: - professional intervention services - referral to formal evaluation - referral to formal treatment - long-term monitoring Source: White, W.L., DuPont, R.L. & Skipper, G.E. (2007)

40. Key ingredients of PHPs • motivational fulcrum: link recovery to positive rewards and relapse to negative consequences (e.g., loss of license) • comprehensive assessment and treatment: patient-oriented treatment rather than a fixed model • care management oversight role: PHPs directs care for physicians so they can select appropriate resources • high expectation for abstinence-based recovery: relapses are seen as temporary setbacks/learning experiences • assertive linkage to recovery support groups: active referrals to 12-step and other recovery-focused mutual aid groups • sustained monitoring support reintervention: periodic interviews/random urine testing over 5 years • reintervention at higher level of intensity: relapse and reintervention are followed by reevaluation and more intensive/prolonged treatment • integrated comprehensive program: PHPs include these items in an integrated and long-sustained program Source: Skipper, G.E. and DuPont, R.L. (2011)

41. PHPs 5-7yr study outcomes (N=904) • 72% completed the contract; a further 22% signed a new one (78% of these voluntarily) • 79% licensed and working at 5-year follow-up • 92% participated in AA or NA; 61% participated in continuing groups • 78% had zero positive tests across 5-7 yrs; 22% had at least one positive test at some point, however, only 1 in 200 drug screens were positive over the 5-7yr monitoring period Source: Du Pont, R.L. et al. (2011)

42. Hawaii Opportunity Probation with Enforcement (HOPE) program • Goal - to reduce drug use, new crimes, and incarceration • Drug-testing-and-sanctions approach • Does not mandate treatment; 12-step participation encouraged • Started as pilot program 2004 with 36 offenders now expanded to over 1500 participants 2009

43. Pilot study by the Integrated Community Sanctions unit in Honolulu Offenders in HOPE vs. comparison offenders • HOPE procedure: - initiation/overview conducted by judge - call HOPE hotline every morning - if selected for testing, must appear by 2pm - if fail to appear or test positive, “Motion to Modify Probation” issued - after immediatehearing, if offender has violated probation, sentenced to short jail stay (several days) - HOPE participation resumes upon release • Probation as usual: - no random drug testing - scheduled appointments with a probation officer once a month

44. Average number of positive UAs, by period. (Hawken et al. , 2009) In a 12-month period 61% of HOPE participants had zero positive UAs Note: Data are from PROBER. For comparison probationers, data reflect urinalysis results for regularly scheduled UAs. For HOPE probationers UAs include regularly scheduled tests, and random testing. Pre (3m) refers to the average number of missed appointments in the three months before the study start date (baseline). Follow-up (3m) refers to the average number of missed appointments in the three-month period following baseline and Follow-up (6m) refers to the average number of missed appointments in the six-month period following baseline.

45. Randomized controlled trial of HOPE (N=493) (Hawken et al., 2009) • HOPE vs. probation-as-usual • One year follow up • Results HOPE in comparison with probation-as-usual: • 60% fewer no-shows • 70% fewer positive urine tests • 55% fewer new arrest rates • 53% lower revocation rate • 48% lower incarceration

46. South Dakota’s “24/7 Sobriety” project (Larry Long) • For repeat DUI offenders • Started 1980s in 1 county; 2007 implemented state-wide -replicated in North Dakota • Objective verification of abstinence (twice a day breath, blood or other bodily substance testing • Positive/missed tests results in immediate 24-hour incarceration • No treatment referral or requirement; 12-step attendance encouraged

47. 24/7 Sobriety Outcomes Urinalyses (July 1, 2007-July 20, 2011): • N= 1,990 • 46,648 tests administered • Pass Rate 96.9% SCRAM bracelets (Nov. 6, 2006-July 20, 2011): • N=3,177 • 77.9% had no violations • 22.1% participants had some type of violation Drug patches (July 1, 2007-July 20, 2011): • N=94 • Pass Rate 80% Source: http://apps.sd.gov/atg/dui247/247stats.htm

48. N=446 adults with SUD, mean age = 38, 54% male, 85% African-American • randomly assigned to • quarterly assessment only • quarterly assessment plus RMC • Recovery Management Checkups • Linkage manager who used motivational interviewing to review the participant’s substance use, discuss treatment barrier/solutions, schedule an appointment for treatment re-entry, and accompany participant through the intake • If participants reported no substance use in the previous quarter, the linkage manager reviewed how abstinence has changed their lives and what methods have worked to maintain abstinence Source: Dennis & Scott (2012). Drug and Alcohol Dependence, 121, 10-17

49. Results 1Return to treatment • Participants in RMC condition sig. more likely to return to treatment sooner Source: Dennis & Scott (2012). Drug and Alcohol Dependence, 121, 10-17

50. Results 4Days abstinent (0-1350) Of 18 vars tested, the only variables that predicted return to treatment was the intervention *p<.01