Transcript Preliminary data from the Persistent Effects of Treatment

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: [email protected]
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 1416, 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 [email protected] or 309-820-3805. A
copy of these slides will be posted at www.chestnut.org/li/posters
.
1
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
1. Quantifying the patterns that demonstrate that
substance use disorders are a chronic condition
2. Examining the cycle of relapse, treatment,
incarceration and recovery that characterize the
course of this condition and what predicts transition
3. Presenting the results of two experiments designed
to improve the ways in which this condition is
managed across time and multiple episodes of care.
2
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)
3
Severity of Past Year Substance Use/Disorders
(2002 U.S. Household Population age 12+= 235,143,246)
Dependence 5%
Abuse 4%
Regular AOD
Use 8%
Any Infrequent
Drug Use 4%
Light Alcohol
Use Only 47%
No Alcohol or
Drug Use
32%
4
Source: 2002 NSDUH and Dennis & Scott under review
Problems Vary by Age
NSDUH Age Groups
100
90
80
Adolescent
Onset
Remission
Increasing
rate of nonusers
70
Severity Category
No Alcohol or Drug Use
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
0
Dependence
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
5
Source: 2002 NSDUH and Dennis & Scott under review
Higher Severity is Associated with
Higher Annual Cost to Society Per Person
$4,000
Median (50th percentile)
$3,500
Mean (95% CI)
$3,000
$2,500
$2,000
$1,500
$3,058
This includes people who are in
recovery, elderly, or do not use
because of health problems
$1,613
Higher
Costs
$1,528
$1,309
$1,078
$1,000
$725
$406
$500
$0
$948
$0
$0
No
Alcohol or
Drug Use
Light
Alcohol
Use Only
$231
$231
Any
Infrequent
Drug Use
Regular
AOD
Use
Abuse
Dependence
Source: 2002 NSDUH and Dennis & Scott under review 6
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).
7
Median Length of Stay in Days
The Majority Stay in Tx Less than 90 days
90
60
52
42
33
30
20
0
Outpatient
Intensive
Outpatient
Short Term
Residential
Long Term
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 .
8
Less Than Half Are Positively Discharged
100%
90%
Other
Discharge Status
80%
70%
Terminated
60%
Dropped out
50%
40%
Completed
30%
20%
Transferred
10%
0%
Outpatient
Intensive Short Term Long Term
Outpatient Residential Residential
Less than 10%
are transferred
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
100%
80%
60%
40%
20%
0%
100%
Adol. More
likely to have
externalizing
disorders
80%
60%
40%
20%
0%
Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity
Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[
External Disorders
Crime/Violence
Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)
Exception
Adults
Dependent (n=1221)
Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set
10
Pathways to Recovery Study (Scott & Dennis)
Recruitment:
Sample:
1995 to 1997
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
11
100%
80%
60%
40%
20%
0%
Pathways to Recovery Sample Characteristics
African American
Age 30-49
Female
Current CJ Involved
Past Year Dependence
Prior Treatment
Residential Treatment
Other Mental Disorders
Homeless
Physical Health Problems
12
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
13
Age Distributions
Predominately
Adolescent onset
14
Substance Use Careers Last for Decades
100%
90%
80%
70%
Median
duration of
27 years
(IQR: 18 to
30+)
Percent in Recovery
60%
50%
40%
30%
20%
10%
0%
0
5
10
15
20
25
Years from first use to 1+ years abstinence
30
Source: Dennis et
al 2005 (n=1,271) 15
100%
90%
21+
80%
15-20*
70%
Percent in Recovery
60%
under 15*
50%
40%
Age of 1st Use Groups
Substance Use Careers are Longer,
the Younger the Age of First Use
30%
20%
10%
0%
* p<.05
(different
from 21+)
0
5
10
15
20
25
Years from first use to 1+ years abstinence
30
Source: Dennis et
al 2005 (n=1,271) 16
100%
90%
0-9*
80%
10-19*
70%
Percent in Recovery
60%
50%
40%
20+
Years to 1st Tx Groups
Substance Use Careers are Shorter
the Sooner People get to Treatment
30%
20%
10%
0%
* p<.05 (different
from 20+)
0
5
10
15
20
25
Years from first use to 1+ years abstinence
30
Source: Dennis et
al 2005 (n=1,271) 17
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
60%
50%
40%
30%
20%
10%
0% 0
5
10
15
20
Years from first Tx to 1+ years abstinence
25
Source: Dennis et
al 2005 (n=1,271) 18
Over 55% Continued to Changed Status Between
Annual Follow-up Interviews (83% over 3 years)
Status at 36 months
100%
90%
80%
In the
community
In Recovery
70%
60%
50%
40%
In Treatment
Incarcerated
30%
20%
In the
community
using
10%
0%
In the Community Using
(57%)
Inc. In Tx.
(6%) (12%)
Recovery
(26%)
Status at 24 months
19
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery
P not the same in
both directions
Incarcerated
(37% stable)
6%
7%
25%
30%
In the
Community
Using
(53% stable)
8%
13%
28%
In Recovery
(58% stable)
29%
4%
44%
31%
In Treatment
(21% stable)
Source: Scott et al 2005
7%
Treatment is the
most likely path
to recovery
20
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
Community
Using
(53% stable)
13%
In Recovery
(58% stable)
29%
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
21
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.
22
The Early Re-Intervention (ERI) Experiments
(Dennis & Scott)
ERI 1
ERI 2
Recruitment
Recruited 448 from
Community Based Treatment
in Chicago in 2000 (84% of
eligible recruited)
Recruited 446 from
Community Based Treatment
in Chicago in 2004 (93% of
eligible recruited)
Design
Random assignment to
Recovery Management
Checkups (RMC) or control
Random assignment to
Recovery Management
Checkups (RMC) or control
Follow-Up
Quarterly for 2 years (9597% per wave)
Quarterly for 4 years (95 to
97% per wave)
Data Sources GAIN, CEST, Urine, Salvia
Staff logs
GAIN, CEST, CAI, Neo,
CRI, Urine, Staff logs
Publication
Dennis & Scott (under
review); Scott & Dennis,
(under review)
Dennis, Scott & Funk 2003;
Scott, Dennis & Foss, 2005
Funding Source NIDA grant R37-DA11323
23
100%
80%
60%
40%
20%
0%
Sample Characteristics of ERI-1 & -2 Experiments
African American
Age 30-49
Female
Current CJ Involved
Past Year Dependence
Prior Treatment
Residential Treatment
Other Mental Disorders
Homeless
ERI 1 (n=448)
Physical Health Problems
ERI 2 (n=446)
24
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…
(a) During the past 90 days, have you used alcohol,
marijuana, cocaine, or other drugs on 13 or more days?
(b) During the past 90 days, have you gotten drunk or been
high for most of 1 or more days?
(c) 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?
(d) During the past week, had withdrawal symptoms when you
tried to stop, cut down, or control your use?
(e) Do you feel that you need to return to treatment?
(f) During the past month, has your substance use caused you
any problems?
Note alpha > .90
25
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
26
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
27
False Negative Rates by Time and Experiment
50%
40%
30%
Any Drug Tested Reported
Any AOD or Medication Reported \c
ERI 2 False
Negative Rates
Lower and
Going Down
19%
20%
15%
15%
10%
Any AOD Reported \b
ERI 1 False
Negative Rates
High and Going
Up
9%
9%
5%
4%
0%
12 Months
ERI 1 (n=350)
24 Months
ERI 1 (n=313)
3%
1%
12 Months
ERI 2 (n=424)
3% 2%
1%
24 Months
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
28
RMC Protocol Adherence Rate by Experiment
100%
Quality
assurance
and transportation
Generally
averaged
as well
assistance reduced
the variance
or better
90%
80%
70%
60%
Improved
Screening
50%
40%
Improved
Tx
Engagement
30%
20%
10%
0%
Follow-up Treatment
Need
Interview
(93 vs. 96%)
d=0.18*
(30 vs. 44%)
d=0.31*
ERI-1
ERI-2
<-Average->
Linkage
Agreed to Showed to Showed to Treatment
Attendance Assessment Assessment Treatment Engagement
(75 vs. 99%)
d=1.45*
(44 vs. 45%)
d=0.02
(30 vs. 42%)
d=0.26*
Range of rates by quarter
(25 vs. 30%)
d=0.18*
(39 vs. 58%)
d=0.43*
* P(H: RMC1=RMC2)<.05
29
ERI-1 Time to Treatment Re-Entry
100%
Percent Readmitted 1+ Times
90%
80%
630-403 = -200 days
70%
60% ERI-1 RMC*
(n=221)
51% ERI-1 OM
(n=224)
60%
50%
40%
30%
20%
Revisions to
the protocol
10%
0
% 0
90
180
270
360
450
540
*Cohen's d=+0.21
Wilcoxon-Gehen
Statistic (df=1)
630
=2.78, p <.05
Days to Re-Admission (from 3 month interview)
30
ERI-2 Time to Treatment Re-Entry
100%
The size of the effect is
growing every quarter
Percent Readmitted 1+ Times
90%
80%
70%
630-246 = -384 days
60%
55% ERI-2 RMC*
(n=221)
50%
40%
37% ERI-2 OM
(n=224)
30%
20%
10%
0%
0
90
180
270
360
450
540
*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=18.86, p <.0001
Days to Re-Admission (from 3 month interview)
31
ERI-1: Impact on Outcomes
100%
90%
80%
Months 4-24
No effect on Abstinence/Symptoms
79% 79%
70%
Percentage
Final Interview
60%
RMC
Broke the
Run
80% 79%
OM
RMC
Less Likely to be in
Need of Treatment
56%
50%
43%
40%
26%
30%
21%
21% 21%
20%
10%
0%
of 630 Days
Abstinent
(d=0.00)
of 7 Subsequent
Quarters in Need
(d= -0.15) *
of 90 Days
Abstinent
(d= -0.05)
of 11 Sx of
Abuse/Dependence
(d=0.01)
Still in need
of Tx
(d= -0.30) *
* p<.05
32
ERI-2: Impact on Outcomes
100%
Months 4-24
Significant Increase in Abstinence
90%
76%
80%
Percentage
70%
Final Interview
68%
60%
RMC
Broke the
Run
75%
RMC
Less Likely to be in
Need of Treatment
67%
Less
Symptoms
46%
50%
OM
54%
42%
35%
40%
28%
30%
19%
20%
10%
0%
of 630 Days
Abstinent
(d=0.29)*
of 7 Subsequent
Quarters in Need
(d= -0.29) *
of 90 Days
Abstinent
(d= 0.23)*
of 11 Sx of
Abuse/Dependence
(d= -0.23)*
Still in need
of Tx
(d= -0.29) *
* p<.05
33
As expected, 32% of individuals change status between
the beginning and end of the quarter (82% over 2 years)
Status at the end of Quarter
End of
Quarter
100%
90%
80%
In the
community
In Recovery
70%
60%
50%
40%
In Treatment
30%
20%
Incarcerated
In the
community
using
10%
0%
In the Community Using
(41%)
Inc.
(5%)
In Tx.
(12%)
Recovery
(42%)
(3,136 quarterly
transition 34
Status at beginning
of Quarter
Beginning of Quarter
Observations on 448 unique people)
Impact on Primary Pathways to Recovery
(incarceration not shown)
17%
18%
In the
Communityy
Using
(71% stable)
27%
Transition to Tx
- Freq. of Use (0.7)
+ Prob. Orient. (1.4)
+ Desire for Help (1.6)
+ RMC (3.22)
In Recovery
(76% stable)
8%
33%
In Treatment
(35% stable)
Source: ERI experiments (Scott, Dennis, & Foss, 2005)
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)
5%
Again the
Probability of
Entering Recovery
is Higher from
Treatment
35
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
36
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
37
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 cooccurring 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.
38
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
39
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
40
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 cooccurring 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)
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