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Addiction: What Every Judge Should Know

Addiction: What Every Judge Should Know

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Addiction: What Every Judge Should Know

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  1. Addiction: What Every Judge Should Know Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation at “Addiction: What Every Judge Should Know” workshop, March 5, 2009, Paul Brown Stadium, Cincinnati, Ohio. This presentation was supported by funds from Ohio Supreme Court and Bureau of Justice Assistance Edward Byrne Competitive National Interest Grant no 2008-DD-BX-0710 and using data from NIDA grants no. 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. Goals of this Presentation are to • Illustrate the Chronic Nature of Addiction and the Correlates of Recovery • Demonstrate the Feasibility of Managing Addiction Across Episodes of Treatment to Improve Long Term Outcomes • Identify the Common Gaps in the Existing Treatment System and What it Means to Move it Toward Evidenced Based Practice • Demonstrate the Usefulness of Practice Based Evidence to Inform Clinical Decision Making About Placement and Treatment Planning

  3. Illustrate the Chronic Nature of Addiction and the Correlates of Recovery

  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; Dennis & Scott 2007

  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; Dennis & Scott 2007

  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 Regular AOD Light Alcohol No Alcohol or Any Dependence Abuse Infrequent Use Drug Use Use Only Drug Use Source: 2002 NSDUH; Dennis & Scott 2007

  7. Brain Activity on PET Scan After Using Cocaine Rapid rise in brain activity after taking cocaine Actually ends up lower than they started 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.

  8. 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) Normal Cocaine Abuser (10 days) Even after 100 days of abstinence activity is still low 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.

  9. Serotonin Present in Cerebral Cortex Neurons Still not back to normal after 7 years Reduced in response to excessive use Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

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

  11. Overlap with Crime and Civil Issues • Committing property crime, drug related crimes, gang related crimes, prostitution, and gambling to trade or get the money for alcohol or other drugs • Committing more impulsive and/or violent acts while under the influence of alcohol and other drugs • Crime levels peak between ages of 15-20 (periods or increased stimulation and low impulse control in the brain) • Adolescent crime is still the main predictor of adult crime • Parent substance use is intertwined with child maltreatment and neglect – which in turn is associated with more use, mental health problems and perpetration of violence on others

  12. Substance Use Careers Last for Decades 1.0 Median of 27 years from first use to 1+ years abstinence .9 Cumulative Survival .8 .7 Years from first use to 1+ years abstinence .6 .5 .4 .3 .2 .1 0.0 0 5 10 15 20 25 30 Source: Dennis et al., 2005

  13. Substance Use Careers are Longer the Younger the Age of First Use Age of 1st Use Groups 1.0 .9 .8 Cumulative Survival .7 Years from first use to 1+ years abstinence .6 .5 under 15* .4 15-20* .3 .2 21+ .1 0.0 * p<.05 (different from 21+) 0 5 10 15 20 25 30 Source: Dennis et al., 2005

  14. Substance Use Careers are Shorter the Sooner People Get to Treatment Year to 1st Tx Groups 1.0 .9 .8 Cumulative Survival .7 Years from first use to 1+ years abstinence 20+ .6 .5 .4 .3 10-19* .2 .1 0.0 0-9* * p<.05 (different from 20+) 0 5 10 15 20 25 30 Source: Dennis et al., 2005

  15. Treatment Careers Last for Years 1.0 .9 Cumulative Survival .8 Median of 3 to 4 episodes of treatment over 9 years .7 Years from first Tx to 1+ years abstinence .6 .5 .4 .3 .2 .1 0.0 0 5 10 15 20 25 Source: Dennis et al., 2005

  16. SUD Remission Rates are BETTER than Most Major DSM Diagnoses 89% 89% 83% 77% 66% 58% 56% 48% 50% 40% 39% 45% 18% 15% 12% 11% 10% 10% 8% 9% 7% 4% 4% 3% Past Year Remission Remission Rate (% Remission / % Dependent) Lifetime Mental Health Diagnosis and Remission 100% 90% 80% 70% 60% 46% 50% 40% 31% 25% 30% 20% 15% 20% 13% 10% 10% 8% 8% 8% 7% 10% 0% Drug Mood : Alcohol Anxiety : Conduct Any AOD Intermittent Explosive Defiant Oppositional Posttraumatic Stress Externalizing Any Attention Deficit Any Internalizing Lifetime Diagnosis Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication

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

  18. 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 28% In Recovery Community (58% stable) Using 29% (53% stable) 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) Source: Scott, Dennis, & Foss (2005)

  19. Percent Sustaining Abstinence Through Year 8 by Duration of Abstinence at Year 7 Even after 3 to 7 years of abstinence about 14% relapse 100% . 86% 86% 90% It takes a year of abstinence before less than half relapse 80% 66% 70% 60% % Sustaining Abstinent through Year 8 50% 36% 40% 30% 20% 10% 0% 1 to 12 months 1 to 3 years 3 to 5 years 5+ years (n=157; OR=1.0) (n=138; OR=3.4) (n=59; OR=11.2) (n=96; OR=11.2) Duration of Abstinence at Year 7 Source: Dennis, Foss & Scott (2007)

  20. 1-3 Years: Decrease in Illegal Activity; Increase in Psych Problems 5-8 Years: Improved Psychological Status 3-5 Years: Improved Vocational and Financial Status 1-12 Months: Immediate increase in clean and sober friend % of Clean and Sober Friens % Days of Illegal Activity (of 30 days) % Days Worked For Pay (of 22) % Days of Psych Prob (of 30 days) % Above Poverty Line Other Aspects of Recovery by Duration of Abstinence of 8 Years 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs (N=661) (N=232) (N=127) (N=65) (N=77) Source: Dennis, Foss & Scott (2007)

  21. The Risk of Death goes down with years of sustained abstinence 15% 15% 14% 14% 13% 13% 12% 12% 11% 11% 10% 10% 9% 9% 8% 8% 7% 7% 6% 6% 4.5% 5% 5% 4% 4% 3% 3% 2% 2% 1% 1% 0% 0% Household Household Less than 1 Less than 1 1 1 - - 3 Years 3 Years 4 4 - - 8 Years 8 Years (OR=1.00) (OR=1.00) (OR=2.87) (OR=2.87) (OR=1.61) (OR=1.61) (OR=0.84) (OR=0.84) Death Rate by Years of Abstinence Users/ Early Abstainers 2.87 times more likely to die in the next year It takes 4 or more years of abstinence for risk to get down to community levels 11.9% 7.1% 3.8% Source: Scott, Dennis, & Funk (2008)

  22. These studies provide converging evidence demonstrating that • Addiction is a brain disorder with the highest risk being during the period of adolescent to young adult brain development • Addiction is chronic in the sense that it often lasts for years, the risk of relapse is high, and multiple interventions are likely to be needed • Yet over two thirds of the people with addiction do achieve recovery • Treatment increases the likelihood of transitioning from use to recovery • Self help, peers and recovery environment help predict who stays there • Recovery is broader than just abstinence

  23. Demonstrate the Feasibility of Managing Addiction Across Episodes of Treatment to Improve Long Term Outcomes

  24. Lots of Geographic Variation in AOD Disorders Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

  25. Cumulative Recovery Pattern at 30 months 5% Sustained Recovery 37% Sustained 19% Intermittent, Problems currently in recovery 39% Intermittent, currently not in recovery The Majority of Adolescents Cycle in and out of Recovery Source: Dennis et al, forthcoming

  26. Recovery* by Level of Care 100% Outpatient (+79%, -1%) 90% Residential(+143%, +17%) 80% Post Corr/Res (+220%, +18%) 70% CC better 60% Percent in Past Month Recovery* 50% OP & Resid Similar 40% 30% 20% 10% 0% Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12 * 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)

  27. There Have Been Several Recent Reviews Dennis & Scott (2007) review of evidenced related to understanding and managing addiction as a chronic condition Marlowe (2008) and Bhati et al (2008) meta analyses of Drug Treatment Court Effectiveness and Cost-Effectiveness Mckay’s (in press) review of 22 experiments and quasi experiments managing addiction over time found improved outcomes in 38% of those focused on less than 3 months, 44% on those that focused on 3 to 12 months and 100% of those that focused on more than 12 months

  28. Experiments with Continuing Care Assertive Continuing Care 1 (ACC-2) experiment with 183 adolescents discharged from residential substance abuse treatment and followed for 9 months in 1997-2004 Assertive Continuing Care 2 (ACC-2) experiment with 342 adolescents discharged from residential substance abuse treatment and followed for 12 months in 2005-2008 Assertive Outpatient Continuing Care Study (AOCCS) experiment with 320 adolescents admitted to outpatient substance abuse treatment and followed for 12 months in 2003-2008

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

  30. 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)

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

  32. UCC ACC * p<.05 ACC Improved Adherence 100% 20% 30% 10% 40% 50% 60% 70% 80% 90% 0% Weekly Tx Weekly 12 step meetings Relapse prevention* Communication skills training* Problem solving component* Regular urine tests Meet with parents 1-2x month* Weekly telephone contact* Contact w/probation/school Referrals to other services* Follow up on referrals* Discuss probation/school compliance* Adherence: Meets 7/12 criteria* Source: Godley et al 2002, 2007

  33. 55% 55% 43% High (7-12/12) GCCA * p<.05 GCCA Improved Early (0-3 mon.) Abstinence 100% 90% 80% 70% 60% 50% 38% 36% 40% 30% 24% 20% 10% 0% Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA Source: Godley et al 2002, 2007

  34. 73% 69% 59% Early (0-3 mon.) Abstainer * p<.05 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence 100% 90% 80% 70% 60% 50% 40% 30% 22% 22% 19% 20% 10% 0% Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*) Early(0-3 mon.) Relapse Source: Godley et al 2002, 2007

  35. Weak Levels of Expert Testimony Science Relating Standards of Proof to Science Law Meta Analyses of Experiments/ Quasi Experiments (Summary v Predictive, Specificity, Replicated, Consistency) Dismantling/ Matching study (What worked for whom) Experimental Studies (Multi-site,Independent,Replicated, Fidelity, Consistency) Quasi-Experiments (Quality of Matching, Multi-site,Independent,Replicated, Consistency) Pre-Post (multiple waves), Expert Consensus Correlation and Observational studies Case Studies, Focus Groups Pre-data Theories, Logic Models Anecdotes, Analogies STRONGER Beyond a Reasonable Doubt Clear and Convincing Evidence Preponderance of the Evidence Probable Cause Reasonable Suspicion Source: Marlowe 2008

  36. Science Relating Standards of Proof to Science Law Meta Analyses of Experiments/ Quasi Experiments (Summary v Predictive, Specificity, Replicated, Consistency) Dismantling/ Matching study (What worked for whom) Experimental Studies (Multi-site,Independent,Replicated, Fidelity, Consistency) Quasi-Experiments (Quality of Matching, Multi-site,Independent,Replicated, Consistency) Pre-Post (multiple waves), Expert Consensus Correlation and Observational studies Case Studies, Focus Groups Pre-data Theories, Logic Models Anecdotes, Analogies STRONGER Beyond a Reasonable Doubt Adult Drug Treatment Courts 5 meta analyses of 76 studies found crime reduced 7-26% with $1.74 to $6.32 return on investment Clear and Convincing Evidence Family Drug Treatment Courts – one multisite quasi experiment with positive findings for parent and child Preponderance of the Evidence DWI Treatment Courts – one quasi experiment and five observational studies with effect sizes of 0 to .45 and one quasi experiment (effect size=.29 to .57) Probable Cause Reasonable Suspicion Juvenile Drug Treatment Courts, Mental Health Treatment Courts – multiple small studies with mix of positive, null and negative findings

  37. Potential Cost Savings of Expanding Diversion to Treatment Programs in Justice Settings • Currently treating about 55,000 people in these courts at a cost of $515 million with an average return on investment (ROI) of $2.14 per dollar • The ROI is higher (2.71) for those with more crime • It is estimated that there are at least twice as many people in need of drug court as getting it • Investing the $1 billion to treat them would likely produce a ROI of $2.17 billion to society Source: 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.

  38. Experiments with Recovery Management Checkups to Manage Addiction Over Years • Early Re-Intervention (ERI) Experiment 1 – 448 adults entering treatment followed for 2-years from 2000-2002 • Early Re-Intervention (ERI) Experiment 2 – 446 adults entering treatment followed for 5-years from 2004-2009 • Women Offenders – 450 women coming out of Cook County jail and followed for 3-years from 2008-2013 • Early Re-Intervention for Adolescents (ERI-A) – feasibility studies currently being conducted with over longitudinal data on over 4,000 adolescents

  39. Recovery Management Checkup (RMC) • 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 • Treatment Engagement Specialist

  40. 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 RMC increases the odds of transitioning from using to treatment within a quarter by 2.1 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) =16.56, p <.0001 Days to Re-Admission (from 3 month interview) Source: Scott & Dennis (in press)

  41. More days of abstinent RMC Increased Treatment Participation RMC Increased Treatment Participation Less likely to be in Need at 45m Fewer Seq. Quarters in Need 74% 71% 61% 47% 38% ERI-2: Impact on Outcomes at 45 Months OM RMC 100% 90% 80% 70% 67% 56% 60% 55% 50% Percentage 50% 41% 40% 30% 20% 10% 0% of 180 Days of 14 Subsequent Re-entered of 1260 Days Still in need of Tx at Mon 45 of Treatment Quarters in Need Treatment Abstinent (d=0.22)* (d= 0.26) * (d= 0.26)* (d= -0.32)* (d= -0.22) * * p<.05 Source: Scott & Dennis (in press)

  42. 4% 3% 13% 23% 8% 10% 24% 7% 6% 25% 35% 10% Again the Probability of Entering Recovery is Higher from Treatment ERI 2: Average Quarterly Transitions over 3 years 34% Changed Status in an Average Quarter Incarcerated (56% stable) In the In Recovery Community (58% stable) Using (75% stable) In Treatment (32% stable) Source: Riley, Scott & Dennis, 2008

  43. In Recovery (58% stable) 25% 35% ERI 2: Average Quarterly Transitions over 3 years • Transition Tx to Recovery (vs. relapse) • Freq. of Use (0.01) + Wks Self Help (1.39) • Tx Resistance (0.79) +Self Help Act. (1.31) In the Community Using (75% stable) 10% Transition to Tx (vs use) - Tx Resistance (0.93) + Freq. of Use (25.30) + Desire for Help (1.23) + Wks of Self Help (1.51) + Self Help Act. (1.37) + Prior Wks of Tx (1.07) + RMC (2.08) In Treatment (32% stable) Source: Riley, Scott & Dennis, 2008

  44. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents More likely than adults to be diverted to treatment (OR=4.0) P not the same in both directions 3% 5% 10% 20% 24% 12% 27% 7 % 7% 19% 26% 7% Treatment is the most likely path to recovery More likely than adults to stay 90 days in treatment (OR=1.7) Incarcerated (46% stable) In the In Recovery Community (62% stable) Using (75% stable) Avg of 39% change status each quarter In Treatment (48% stable) Source: Dennis et al 2007. 2006 CSAT AT data set

  45. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents • Probability of Going from Use to Early “Recovery” (+ good) • Age (0.8) + Female (1.7), • Frequency Of Use (0.23) + Non-White (1.6) • + Self efficacy to resist relapse (1.4) • + Substance Abuse Treatment Index (1.96) In the 12% In Recovery Community (62% stable) Using 27% (75% stable) Probability of Sustaining Recovery vs. Relapsing (+ good) - Freq. Of Use (0.0002) + Initial Weeks in Treatment (1.03) - Illegal Activity (0.70) + Treatment Received During Quarter (2.00) - Age (0.81) + Recovery Environment (r)* (1.45) + Positive Social Peers (r) (1.43) • * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home • ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.

  46. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents • Probability of Going from Use to “Treatment” (+ good) • Age (0.7) + Times urine Tested (1.7), • + Treatment Motivation (1.6) • + Weeks in a Controlled Environment (1.4) In the Community Using (75% stable) 7% In Treatment (48 v 35% stable) Source: Dennis et al 2007. 2006 CSAT AT data set

  47. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents • Probability of Going to Using vs. Early “Recovery” (+ good) • - Baseline Substance Use Severity (0.74) + Baseline Total Symptom Count (1.46) • - Past Month Substance Problems (0.48) + Times Urine Screened (1.56) • - Substance Frequency (0.48) + Recovery Environment (r)* (1.47) • + Positive Social Peers (r)** (1.69) In the In Recovery Community (62% stable) Using (75% stable) 26% 19% • * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home • ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity. In Treatment (48 v 35% stable) Source: Dennis et al 2007. 2006 CSAT AT data set

  48. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery: Adolescents Probability of Going to Using vs. Early “Recovery” (+ good) + Recovery Environment (r)* (3.33) Incarcerated (46% stable) 10% 20% In the In Recovery Community (62% stable) Using (75% stable) * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home Source: Dennis et al 2007. 2006 CSAT AT data set

  49. These studies provide converging evidence demonstrating that • More assertive continuing care can increase adherence with continuing care expectations • A growing range of drug treatment courts are being found effective and cost effective • Recovery management checkups can identify people who have relapsed and get them back to treatment faster • That doing each improves short and long term outcomes • That it appears feasible to extend recovery management checkups to adolescents, but that there is a need to focus even more on recovery environment and peer groups

  50. Identify the Common Gaps in the Existing Treatment System and What it Means to Move it Toward Evidenced Based Practice