Transcript Preliminary data from the Persistent Effects of Treatment

Research on
Understanding and Managing
Addiction as a Chronic Condition
Michael L. Dennis, Ph.D.
Chestnut Health Systems
Normal, IL
Presentation at the 53rd International Council on Alcohol and Addiction (ICAA) and
Centros de Integración Juvenil (CIJ) Conference on Dependencies "New Challenges New Solutions", November 3 to 6, 2010, Cancun, Mexico. This presentation was
supported by funds and data from NIDA grants no. R01 DA15523 (C.Scott), R37DA11323 (M.Dennis), CSAT contract no. 270-07-0191 (M.Dennis) and several other
authors/studies. It is available electronically at www.chestnut.org/li/posters. The
opinions are those of the author and do not reflect official positions of the
government. Please address comments or questions
to the author at [email protected] or 309-451-7801.
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1
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
2
Prolonged Substance Use Injures The Brain:
Healing Takes Time
Normal levels of
brain activity in PET
scans show up in
yellow to red
Reduced brain
activity after regular
use can be seen
even after 10 days
of abstinence
Normal
10 days of abstinence
After 100 days of
abstinence, we can
see brain activity
“starting” to recover
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.
3
Adolescent Brain
Development Occurs from the
Inside to Out and
Front
Photo courtesy offrom
the NIDABack
Web site.to
From
A
Slide Teaching Packet: The Brain and the
Actions of Cocaine, Opiates, and Marijuana.
pain
4
Alcohol and Other Drug Abuse, Dependence and
Problem Use Peaks at Age 20
100
90
80
70
Percentage
60
Over 90% of
use and
problems
start between
the ages of
12-20
People with drug
dependence die an
average of 22.5 years
sooner than those
without a diagnosis
It takes decades before
most recover or die
Severity Category
Other drug or
heavy alcohol use
in the past year
50
40
30
Alcohol or Drug Use
(AOD) Abuse or
Dependence in the
past year
20
10
0
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
Age
5
Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000
Substance Use Disorders are Common,
But Treatment Participation Rates Are Low:
United States Over
(US)
88% of adolescent and
Few Get Treatment:
1 in 19 adolescents,
1 in 21 young adults,
25%
1 in 12 adults
young adult treatment and
over 50% of adult treatment
is publicly funded
20.9%
20%
15%
10%
7.8%
7.2%
5%
0.4%
1.0%
Much of the private
funding is limited to 30
days or less and
authorized day by day
or week by week
0.5%
0%
12 to 17
18 to 25
26 or older
Abuse or Dependence in past year
Treatment in past year
6
Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH
Percent still using
People Entering Publicly Funded
Treatment Generally Use For Decades
It takes 27 years
before half reach
1 or more years of
abstinence or die
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
Source: Dennis et al., 2005
30
7
Percent still using
The Younger They Start,
The Longer They Use
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Age of
First Use
under 15*
60% longer
15-20
21+
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
Source: Dennis et al., 2005
30
* p<.05
8
Percent still using
The Sooner They Get To Treatment,
The Quicker They Get To Abstinence
Years to
first
Treatment
Admission*
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
20 or
more
years
57% quicker
10 to 19
years
0
5
10
15
20
25
Years from first use to 1+ years of abstinence
Source: Dennis et al., 2005
0 to 9
30 years
* p<.05
9
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
10
.
The Likelihood of Sustaining Abstinence
After 4 years of
Another Year Grows Over Time
abstinence, about
After 1 to 3 years of
abstinence, 2/3rds will
make it another year
100%
% Sustaining Abstinence
Another Year
90%
80%
70%
60%
Only a third of
people with
1 to 12 months of
abstinence will
sustain it
another year
86% will make it
another year
86%
66%
50%
40%
36%
30%
20%
10%
0%
1 to 12 months
1 to 3 years
Duration of Abstinence*
Source: Dennis, Foss & Scott (2007)
4 to 7 years
But even after 7 years
of abstinence, about
14% relapse* each
p<.05year 11
What does recovery look like on average?
1-12 Months
Duration of Abstinence
1-3 Years
4-7 Years
• 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
• Virtual elimination of illegal activity and illegal
income
• Better housing and living situations
• Increasing employment and income
• 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
Source: Dennis, Foss & Scott (2007)
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Deaths in the next 12 months
Sustained Abstinence Also Reduces
The Risk of Death*
The Risk of Death
goes down with
years of sustained
abstinence
Users/Early
Abstainers
more likely
to die in
the next 12
months
It takes 4 or
more years of
abstinence for
risk to get
down to
community
levels
(Matched on Gender,
Race & Age)
Source: Scott, Dennis, Laudet, Funk & Simeone (in press)
* p<.05
13
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)
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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
15
ERI-2 Time to Treatment Re-Entry at Year 4
100%
Time from relapse to
readmission reduce by
78% (45-13 = -32
months; d=-.41)
Percent Readmitted 1+ Times
90%
80%
70%
RMC increases the
odds of re-entering
treatment over
4 years by 3.1
74% ERI-2 RMC*
(n=198)
60%
48% ERI-2 OM
(n=195)
50%
40%
30%
20%
The size of the effect is
growing every quarter
10%
0%
0
3
Wilcoxon-Gehen
6 9 12 15 18 21 24 27 30 33 36 39 42 45 statistic (df=1)
= 28.60, p<.001
Months from 1st Follow-up In Need for Treatment
,
OR=3.1, p<.05
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Source: Scott & Dennis (2009); Dennis & Scott (under review)
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
17
Source: Scott & Dennis (2009); Dennis & Scott (under review)
Screening & Brief Inter.(1-2 days)
In-prison Therap. Com. (28 weeks)
Outpatient (18 weeks)
Intensive Outpatient (12 weeks)
Treatment Drug Court (46 weeks)
Residential (13 weeks)
Methadone Maintenance (87 weeks)
Therapeutic Community (33 weeks)
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$0
Cost of Substance Abuse Treatment Episode
$407
• $750 per night in Detox
$1,249
• $1,115 per night in hospital
$1,132
• $13,000 per week in intensive
care for premature baby
$1,384
• $27,000 per robbery
$2,486
• $67,000 per assault
$2,907
$4,277
$14,818
$22,000 / year
to incarcerate
an adult
$30,000/
child-year in
foster care
Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004
$70,000/year to
keep a child in
detention
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Investing in Treatment has a Positive Annual
Return on Investment (ROI)
• Substance abuse treatment has been shown to
have a ROI of between $1.28 to $7.26 per
dollar invested
• Treatment drug courts have an average ROI of
$2.14 to $2.71 per dollar invested
This also means that for every dollar treatment
is cut, we lose more money than we saved.
Source: Bhati et al., (2008); Ettner et al., (2006)
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Summary Points
• Addiction can be a chronic condition with
high costs to the individual and society
• Getting people to 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
20
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., 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 (under review). Four-year outcomes from the Early Re-Intervention Experiment (ERI) with Recovery
Management Checkups (RMC). Normal, IL: Chestnut Health Systems.
• 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.
• 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
• 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, 104, 959-971.
• Scott, C. K., & Dennis, M. L. (in press). Recovery management checkups with adult chronic substance users. In Kelly, J.F., and White,
W.L. (Eds), Addiction Recovery Management: Theory, Research, and Practice. New York, NY: Springer
• Scott, C. K., Dennis, M. L., Laudet, A., Funk R. & Simeone, R., & (in press). Surviving Drug Addiction: Do treatment and abstinence
reduce mortality? American Journal of Public Health.
• 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 N.D., Fowler J.S., Wang G-J., Hitzemann R., Logan J., Schlyer D., Dewey 5., Wolf A.P. (1993). Decreased dopamine D2
receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177.
• Volkow, N.D., Hitzemann R., Wang C-I., Fowler I.S., Wolf A.P., Dewey S.L. (1992). Long-term frontal brain metabolic changes in
cocaine abusers. Synapse 11:184-190.
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