Transcript Preliminary data from the Persistent Effects of Treatment

Understanding and Managing
Addiction as a Chronic Condition
Michael L. Dennis, Ph.D. and
Christy K Scott, Ph.D.
Chestnut Health Systems
Normal and Chicago, IL
Presentation Mid-Atlantic Regional Dissemination Workshop:
Cutting edge treatment. A CTN Regional Dissemination Conference, Baltimore, MD, on
June 3-4, 2010. This presentation was supported by funds from and data from NIDA grants
no. R01 DA15523, R37-DA11323, R01 DA021174, 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. We would like to thank Belinda Willlis ,
Rodney Funk, and Lilia Hristova, Lisa Nicholson, for their assistance in preparing this
presentation. Please address comments or questions to the author at [email protected] or
309-451-7801.
.p
1
The Goals of this Presentation are to:
1. Illustrate both the chronic nature of substance use disorders
and the reality that sustained recovery is attainable
2. Describe the cyclical nature of addiction and how it relates
to our broader understanding of recovery
3. Discuss the ways in which recovery extends beyond simple
abstinence to include other key life areas.
4. Demonstrate the feasibility of managing addiction via
regular checkups to improve long term outcomes
5. Examine the feasibility of extending the model to target
other populations and impact a broader range of outcomes.
2
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
3
Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000
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
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.
5
The effects on the brain can be long lasting
(Serotonin Present in Cerebral Cortex Neurons)
Reduced in response to excessive use
Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine
Still not back to
normal after 7 years
6
Most people who develop abuse/dependence
Have substance related problems for years
1.00
AOD (median=12 years)
.90
Alcohol (median=10 years)
Percent with Problems
.80
Drugs (median=6 years)
.70
Once they have abuse or
dependence, over half
will have 12 or more
years of AOD problems
.60
.50
.40
.30
.20
.10
.00
0
5
10
15
20
25
Years of SUD Problems from Age of 1st Problems
Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication
30
7
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%
8
Substance Use Disorders are Common, But U.S.
Treatment Participation Rates Are Low
Few Get Treatment:
1 in 17 adolescents,
1 in 22 young adults,
25%
1 in 12 adults
Over 88% of adolescent and
young adult treatment and
over 50% of adult treatment
is publicly funded
21.2%
20%
15%
10%
8.9%
7.3%
5%
0.5%
1.0%
Much of the private
funding is limited to 30
days or less and
authorized day by day
or week by week
0.6%
0%
12 to 17
18 to 25
26 or older
Abuse or Dependence in past year
Treatment in past year
9
Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH
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
$30,000/
child-year in
foster care
$70,000/year to
keep a child in
detention
Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004
10
$22,000 / year
to incarcerate
an adult
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)
11
Pathways to Recovery
(CSAT # T100664, 270977011; NIDA DA15523)
N
1037
Design
9 year longitudinal (annual)
Dates
1995 to 2008
Follow-up Rate
90-95% per wave
Target Population
Treatment Intake
Experimental
Interventions
Target Outcomes
None
Cycles between using, treatment,
incarceration, and recovery
12
Source: Dennis et al., 2005; Scott et al 2005
100%
80%
60%
40%
20%
0%
9- Year Pathways to Recovery Sample (N=1326)
African American
Age 30-49
Female
Current CJ Involved
Past Year Dependence
Prior Treatment
Residential Treatment
Other Mental Disorders
Homeless
Physical Health Problems
13
Source: Dennis et al., 2005; Scott et al 2005
Substance Use Careers Last for Decades
1.0
.9
Median of 27
years from
first use to 1+
years
abstinence
.8
Cumulative Survival
.7
.6
.5
.4
.3
.2
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
14
Substance Use Careers are
Longer the Younger the Age of First Use
1.0
.9
Age of
1st Use
Groups
.8
Cumulative Survival
.7
.6
.5
under 15*
.4
15-20*
.3
.2
21+
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
* p<.05
(different
from 21+)
15
Substance Use Careers are
Shorter the Quicker People Access Treatment
1.0
.9
Year to
1st Tx
Groups
.8
Cumulative Survival
.7
20+
.6
.5
.4
.3
.2
10-19*
.1
0.0
0
5
10
15
20
25
Years from first use to 1+ years abstinence
Source: Dennis et al., 2005
30
0-9*
* p<.05
(different
16
from 20+)
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
Source: Dennis et al., 2005, Scott et al 2005
17
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
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
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)
19
Source: Scott, Dennis, & Foss (2005)
.
The Likelihood of Sustaining Abstinence
After 4 years of
abstinence,
Another Year Grows Over Time
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%
about 86% will
make it
another year
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 year 20
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)
21
Death Rate by Years of Abstinence
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
Users/ Early
Abstainers 2.87
times more
likely to die in
the next year
The Risk of Death
goes down with
years of sustained
abstinence
11.9%
7.1%
4.5%
Household
(OR=1.00)
It takes 4 or
more years of
abstinence for
risk to get
down to
community
levels
3.8%
Less than 1
(OR=2.87)
1-3 Years
(OR=1.61)
Source: Scott, Dennis, Simeone & Funk (forthcoming)
4-8 Years
(OR=0.84)
22
Relationship of Treatment, Abstinence and Death
Age in Decades - Intake
1.82
Chronic Condition - Intake
1.85
Illegal Acts for $ -Intake
1.14
% Time in PH Hospital
- Months 7-96
14.4
No of SA Treatment
Episodes Months 0-6
% Time w Illegal Activity
for $ - Months 7-96
No of SA Treatment
Episodes - Months 7-96
% of Time in SA
Treatment - Months 7-96
Years to
Mortality
0.14
1.32
0.81
0.77
0.75
1.42
Years of
Abstinence
0.68
1.68
0.74
% of Time Abstinent
Months 7-96
Good
Bad
Note: Numbers are Odds Ratio per decade, time or per 10% points
Source: Scott, Dennis, Laudet, Simeone & Funk (under review)
23
Early Re-Intervention Experiment 1 (ERI-1)
(ERI1; DA11323)
N
Design
Dates
Follow-up Rate
Target Population
448
2 year experiment (quarterly)
2000 to 2002
95-98% follow-up
Central Intake
Experimental
Interventions
Recovery Management Checkups
(RMC)
Target Outcomes
Increase Treatment access and
reduce successive quarters using
in community
24
Source: Dennis et al., 2003; Scott et al 2005
Early Re-Intervention Experiment 2 (ERI-2)
(ERI1; DA11323)
N
Design
Dates
Follow-up Rate
Target Population
446
4 year experiment (quarterly)
1997 to 2007
94-97% follow-up
Central Intake
Experimental
Interventions
Recovery Management Checkups
(RMC)
Target Outcomes
Increase Treatment access and
reduce successive quarters using
in community
25
Source: Scott et al 2009, in press
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)
26
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
27
Recovery Management Checkups (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
28
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=+0.22
Wilcoxon-Gehen
Statistic (df=1)
630
=5.15, p <.05
Days to Re-Admission (from 3 month interview)
29
ERI-1: Impact on Outcomes*
Percent
More days of Abstinence
100
90
80
70
60
50
40
30
20
10
0
77
79
Shorter time in
community in
Need of Treatment
33
Days abstinent of 630
(OR=1.1)*
Control
RMC
27
# Sucessive Quarters
Needing Tx out of 7
(OR=0.7)*
* p<.05
30
Source: Dennis, Scott & Funk (2003)
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
31
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)
32
Source: Scott et al 2005, Dennis & Scott, 2007
RMC Protocol Adherence Rate by Experiment
100%
Quality
andaveraged
transportation
ERI assurance
2 Generally
as
assistance
the variance
well or reduced
better than
ERI 1
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
Linkage
Agreed to Showed to Showed to Treatment
Attendance Assessment Assessment Treatment Engagement
(30 vs. 44%)
d=0.31*
ERI-1
ERI-2
<-Average->
Source: Scott & Dennis (in press)
(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
33
ERI-2: Time to Treatment Re-Entry at Year 4
The size of the effect is
growing every quarter
100%
Percent Readmitted 1+ Times
90%
80%
45-13 = -32 months
(d=-.41)
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%
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
34
Source: ERI 2
ERI-2: Impact on Outcomes at 45 Months
100%
90%
RMC Increased
Treatment Participation
80%
74%
71%
Percentage
70%
60%
More
days of
abstinent
61%
67%
55%
50%
OM
Fewer Seq.
Quarters
in Need
50%
41%
RMC
Less likely
to be in
Need at 45m
56%
47%
38%
40%
30%
20%
10%
0%
Re-entered
Treatment
(d=0.22)*
of 180 Days
of Treatment
(d= 0.26) *
Source: Scott & Dennis (2009)
of 1260 Days
Abstinent
(d= 0.26)*
of 14 Subsequent Still in need of
Quarters in Need Tx at Mon 45
(d= -0.32)*
(d= -0.22) *
* p<.05
35
ERI1&2: Impact Treatment Re-entry by
Comorbidity and condition*
100%
90%
80%
RMC’s Impact on
Treatment Participation
was robust across
levels of Comorbidity
Returning to
treatment varied
by Comorbidity*
Percentage
70%
49%
50%
RMC
63%
62%
60%
40%
OM
* p<.05
53%
47%
33%
30%
20%
10%
0%
Substance Use
Disorder (SUD)
(d=0.23)
Substance Use +
Internalizing
Disorders
(d=0.38)
Source: Rush, Dennis, Scott, Castel, & Funk (2008)
Substance Use +
Internalizing +
Externalizing
Disorders
(d=0.31)
36
ERI 2: Average Quarterly Transitions over
3 years
34% Changed
Status in an
Average Quarter
Incarcerated
(56% stable)
4%
3%
13%
23%
In the
Community
Using
(75% stable)
10%
8%
10%
In Recovery
(58% stable)
24%
7%
25%
35%
In Treatment
(32% stable)
6%
Again the
Probability of
Entering Recovery
is Higher from
Treatment
Source: Riley, Scott & Dennis, 2008
37
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 Recovery
(58% stable)
25%
35%
In Treatment
(32% stable)
Source: Riley, Scott & Dennis, 2008
38
ERI-2: Indirect Effects of RMC on Other Outcomes
Random
Assignment to
RMC-WO
Substance
Problems
Psychiatric
Problems
+.29
(-.03, -.11)
Successive
Quarters
of Use (.09)
Crime and
Violence
(+.01, +.14)
+.26
+.43
Psychiatric
Problems (.26)
+.40
(+.19, +.24)
HIV Risk
Behaviors(.22)
+.19
(+.16, +.49)
Arrest/ (.13)
Illegal
Incarceration
Activity (.15)
(+.12, +.03)
HIV Risk
Behaviors
RMC Direct Effects
Other Indirect Effects
Covariates
Common path coefficients
(male, female) coefficients
Variance Explained
Days to Tx
re-entry (.08)
(-.35, -.20)
+.20
+.32
Interpersonal (+.27, +.30)
Violence (.49)
With out Gender: CFI=.95, RMSEA=.048
With Gender Differences: CFI=.95, RMSEA=.028
(+.39, +.53)
(+.21, +.13)
39
RMC for Adolescents Feasibility Study
(DA11323; SAMHSA 270-07-0191)
N
Design
1326
12 month longitudinal (quarterly)
Follow-up Rate
89-92% per wave
Target Population
Treatment Intake
Experimental
Interventions
Target Outcomes
None
Cycles between using, treatment,
incarceration, and recovery
40
Source: Dennis et al (forthcoming)
Cannabis Youth Treatment Experiment:
Cumulative Recovery Pattern at 30 months
5% Sustained
Recovery
37% Sustained
Problems
19% Intermittent,
currently in
recovery
39% Intermittent,
currently not in
recovery
The Majority of Adolescents
Cycle in and out of Recovery
Source: Dennis et al, forthcoming
41
Percent in Past Month Recovery*
CSAT Adolescent Treatment Data Set:
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)
42
The Cyclical Course : Adolescents
P not the same in
both directions
Incarcerated
(46% stable)
5%
10%
20%
In the
Community
Using
(75% stable)
7%
Avg of 39% change
status each quarter
12%
3%
More likely than
adults to be diverted
to treatment
(OR=4.0)
24%
In Recovery
(62% stable)
27%
7%
19%
26%
In Treatment
(48% stable)
More likely than adults to stay 90
Source: 2006 CSAT AT data set
days in treatment (OR=1.7)
7%
Treatment is the
most likely path
to recovery
43
The Cyclical Course : 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
Community
Using
(75% stable)
12%
In Recovery
(62% stable)
27%
Probability of from Recovery to “Using” (+ 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.
44
The Cyclical Course : 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: 2006 CSAT AT data set
45
The Cyclical Course : 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
Community
Using
(75% stable)
In Recovery
(62% stable)
26%
19%
In Treatment
(48 v 35% stable)
Source: 2006 CSAT AT data set
* 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,46
or involved in illegal activity.
The Cyclical Course : Adolescents
Incarcerated
(46% stable)
20%
In the
Community
Using
(75% stable)
10%
In Recovery
(62% stable)
Probability of Going to Using vs. Early “Recovery” (+ good)
+ Recovery Environment (r)* (3.33)
* 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: 2006 CSAT AT data set
47
Results from these studies provide converging
evidence demonstrating that
• Addiction has immediate and lasting effects on the brain.
• Addiction is chronic in the sense that the risk of relapse
persists many years after Tx participation.
• Addiction is cyclical in that individuals cycle through
periods of abstinence, relapse, treatment, and
incarceration before achieving self-sustained recovery.
• Recovery is more than abstinence, and requires
improvements in many key life areas.
• Recovery is common, predictable, and can be proactively
managed – but relapse risk persists
• Gender and multimorbidity are significant moderators
for service needs and recovery resources
48
Next Steps
• Multiple papers published and/or under review
• Anticipating funding the Pathways funding this fall to continue
following the cohort out 18 years post intake as they age into
their 50s and 60s.
• Just completed a 5 year follow-up wave for ERI to evaluate the
impact of “removing” RMC and to evaluate 5 year HIV sero
conversion
• Evaluating the cost, cost-effectiveness and benefit-cost of
RMC
• Just finished recruitment for a 3 year randomized trial of RMC
with women coming out of cook county jailing using RMC
plus new components targeting HIV risk behaviors and
criminal activity
• Planning a pilot study of RMC with adolescents
49
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