Transcript Preliminary data from the Persistent Effects of Treatment

Understanding and Managing
Addiction as a Chronic Condition
Michael L. Dennis, Ph.D.
Chestnut Health Systems
Normal, IL
Presentation at the Pacific Asia Judges Science and Technology Seminar,
November 10-12, 2010, Hyatt Regency Hotel, Tumon, Guam. This
presentation was supported by funds from and data from NIDA grants no.
R01 DA15523, R37-DA11323, R01 DA021174, and CSAT contract no. 27007-0191. It is available electronically at www.chestnut.org/li/posters . The
opinions are those of the author do not reflect official positions of the
government. Please address comments or questions to the author at Chestnut
Health Systems, 448 Wylie Drive, Normal, IL 61761
[email protected] or 309-451-7801.
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
Brain Activity on PET Scan After
Using Cocaine
Rapid rise in brain
activity after taking
cocaine
Actually ends up
lower than they
started
1-2 Min
3-4
5-6
6-7
7-8
8-9
9-10
10-20
20-30
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.
3
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.
4
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
5
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
6
Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000
Yet Recovery is likely and better than average
compared with other Mental Health Diagnoses
SUD Remission Rates
are BETTER than many
other DSM Diagnoses
100%
90%
Median of
8 to 9 years
in recovery
31%
20%
Alcohol
Drug
0%
Lifetime Diagnosis
15%
8%
9%
4%
4%
18%
7%
12%
11%
Past Year Recovery (no past year symptoms)
Recovery Rate (% Recovery / % Dependent)
Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication
3%
Posttraumatic
Stress
7%
8%
Mood :
10%
8%
Anxiety :
10%
10%
Any Internalizing
10%
8%
Attention Deficit
13%
Intermittent
Explosive
15%
Any AOD
10%
46% 40% 39%
45%
25%
30%
20%
56% 48%
50%
Oppositional
Defiant
40%
58%
Conduct
50%
66%
Any
Externalizing
60%
89%
77%
80%
70%
89%
83%
7
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
8
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
9
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
10
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
11
.
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 12
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)
13
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
14
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)
15
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery (Pathway Adults)
Over half change
status annually
P not the same in
both directions
Incarcerated
(37% stable)
6%
7%
25%
30%
In the
Community
Using
(53% stable)
13%
8%
28%
In Recovery
(58% stable)
29%
4%
44%
31%
In Treatment
(21% stable)
Source: Scott, Dennis, & Foss (2005)
7%
Treatment is the
most likely path
to recovery
16
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)
28%
In Recovery
(58% stable)
29%
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)
17
Source: Scott, Dennis, & Foss (2005)
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
18
Investing in Treatment has a Positive Annual
Return on Investment (ROI)2
• Substance abuse treatment has been shown to
have a ROI of between $1.28 to $7.26 per
dollar invested
• Even the long term and more intensive
Treatment Drug Courts programs 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)
19
Early Re-Intervention (ERI) Experiment
and Hypotheses
Monitoring
and
Early ReIntervention
Reduce
Time to Readmission
Less
Successive
Quarters
Using
Less Risk
Behaviors,
MH and
Crime
Relative to Control, RMC will reduce the
time from relapse to readmission
The quicker the return to treatment, the less
successive quarters using in the community
The less quarters using in the community, the less HIV
Risk Behaviors, Mental Health and Crime Problems
Source: Dennis et al 2003, 2007; Scott et al 2005, in press
20
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
21
ERI-2 Time to Treatment Re-Entry at Year 4
RMC increases the
odds of re-entering
treatment over
4 years by 3.1
100%
Time from relapse to
readmission reduce by
78% (45-13 = -32
months; d=-.41)
Percent Readmitted 1+ Times
90%
80%
70%
74% ERI-2 RMC*
(n=198)
60%
48% ERI-2 OM
(n=195)
50%
40%
30%
20%
The size of the effect
grew 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
22
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
23
Source: Scott & Dennis (2009); Dennis & Scott (under review)
ERI 1: Impact on Primary Quarterly
Pathways to Recovery over 2 years
32% Changed
Status in an
Average Quarter
Incarcerated
(60% stable)
3%
2%
16%
15%
In the
Community
Using
(71% stable)
8%
9%
18%
In Recovery
(76% stable)
17%
4%
33%
27%
In Treatment
(35% stable)
5%
Again the
Probability of
Entering Recovery
is Higher from
Treatment
24
Source: Scott et al 2005, Dennis & Scott, 2007
ERI 1: Impact on Primary Quarterly
Pathways to Recovery over 2 years
Transition to Recovery vs Continued Use
- Freq. of Use (0.7)
+ Prob. Orient. (1.3)
- Dep/Abs Prob (0.7)
- Recovery Env. (0.8)
- Access Barriers (0.8)
In the
Community
Using
(71% stable)
+ Self Efficacy (1.2)
+ Self Help Hist (1.2)
+ per 10 wks Tx (1.2)
18%
In Recovery
(76% stable)
8%
Transition to Tx vs.
Continued Use
- Freq. of Use (0.7)
+ Prob. Orient. (1.4)
+ Desire for Help (1.6)
+ RMC (3.22)
In Treatment
(35% stable)
25
Source: Scott et al 2005, Dennis & Scott, 2007
Adolescents: Also Have Complex Pathways to
Recovery
What predicts who enters
and maintains recovery?
Incarcerated
(41% stable)
4%
16%
17%
In the
Community
Using
(60% stable)
17%
Avg of 48% change
status each quarter
18%
4%
27%
In Recovery
(61% stable)
21%
9%
22%
24%
In Treatment
(45% stable)
Source: 2009 CSAT AT data set; unique n = 11,710
14%
Treatment is the
most likely path
to recovery
26
Risk and Protective Factors Associated with
Transitioning to/Remaining in Recovery
• Risk Factors
• Protective Factors
– Older
– Younger
– Male
– Female
– Racial Minority
– Caucasian
– Recent Treatment
– Substance Problems
Substance Frequency – Number of drug screens
– Attend 12 Step Meetings
– Repeated Treatment
– Positive Social Peers
– Emotional Problems
– Positive Recovery
– Illegal Activity
Environment
– Employment
– School Attendance/
Conduct
Source: 2009 CSAT AT data set; unique n = 11,710
27
Cumulative Recovery Pattern
30 Months After Intake
5% Sustained
Recovery
37% Sustained
Problems
19% Intermittent,
currently in
recovery
39% Intermittent,
currently not in
recovery
(n=600 adolescents)
The Majority of Adolescents
Cycle in and out of Recovery
Source: Godley et al 2004
28
Percent in Past Month Recovery*
Recovery* by Level of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
CC
better
OP &
Resid
Similar
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)
29
Time to Enter Continuing Care and Relapse
after Residential Treatment (Age 12-17)
100%
Percent of Clients
90%
80%
70%
Relapse
60%
50%
Cont.
Care
Admis.
40%
30%
20%
10%
0%
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
30
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
Assertive Continuing Care (ACC)
Experiment (n=183) and Hypotheses
General
Continuin
g Care
Adherence
Assertive
Continuin
g Care
Early
Abstinence
Sustained
Abstinence
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.
31
Source: Godley et al 2002, 2007
Assertive Continuing Care (ACC)
Enhancements
•
•
•
•
Continue to participate in UCC
Home Visits
Sessions for adolescent, parents, and together
Sessions based on Adolescent Community
Reinforcement Approach (A-CRA) 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)
Source: Godley et al 2002, 2007
32
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
General Continuing Care Adherence (GCCA)
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
UCC
ACC
* p<.05
33
Adherence Improved Early (0-3 mon.) Abstinence
100%
90%
80%
70%
60%
55%
50%
43%
36%
40%
30%
55%
38%
24%
20%
10%
0%
Any AOD (OR=2.16*)
Low (0-6/12) GCCA
Source: Godley et al 2002, 2007
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Marijuana (OR=1.98*)
* p<.05
34
Opportunities to Better Support Recovery
Evidenced Based Recovery Services for
Adolescents (1-2 Clinical Trials)
•
•
•
•
Telephone Counseling
Assertive Continuing Care
Contingency Managements
Recovery Coaches or Mentors
Other Promising Recovery Services
•
•
•
•
•
Alcohol/Drug Test Monitoring
Self Help Participation
Community Reinforcement Approach Family Training (CRAFT)
Recovery School
Recovery oriented support via technology (ie text, email, social
networking, skype)
35
Summary Points
• Addiction can be a chronic condition with
high costs to the individual and society
• Getting people to sustained 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
36
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.
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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., Coleman, V., Scott, C.K & Funk, R (forthcoming). The Prevalence of Remission from Major Mental Health Disorder
in the US: Findings from the National Co morbidity Study Replication.
• 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
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Substance Abuse Treatment, 28, S51-S62.
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chronic substance use disorders. Evaluation and Program Planning, 26(3), 339-352.
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MD: Substance Abuse and Mental Health Services
Administration. http://www.oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm#7.3.1
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substance abuse treatment and from treatment to recovery. Poster presented at the UCLA Center for Advancing Longitudinal Drug
Abuse Research Annual Conference, August 13-15, 2008, Los Angles, CA. www.caldar.org .
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Management Checkups with Adult Chronic Substance Users. Addiction.
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duration of abstinence . Poster 119 at the College of Problems on Drug Dependence (CPDD) Annual Meeting, San Juan, PR, June 16,
2008. Available at www.chestnut.org/li/posters .
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Substance Abuse Treatment, 28, S61-S70.
• Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. (1993). Decreased dopamine D2 receptor
availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177.
• Volkow, ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. (1992). Long-term frontal brain metabolic changes in cocaine 37
abusers. Synapse 11:184-190.