Transcript In Recovery - William White Papers

Findings from the Pathways to Recovery
and Recovery Management Checkups
(RMC) Experiments
Michael L. Dennis, Ph.D.
& Christy K Scott, Ph.D.
Chestnut Health Systems
Bloomington and Chicago, IL
Presentation at the State Systems Development Program VIII Conference: Partnering to
Support Recovery-Oriented Systems of Care, Washington, DC, August 20-22, 2008. This
presentation was supported by funds from and data from NIDA grants no. R01 DA15523, R37DA11323 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
[email protected] or 309-820-3805.
.
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 present
1. Epidemiological data to illustrate the chronic nature
of substance disorders and how it relates to a
broader understanding of recovery
2. The results of two experiments designed to improve
the ways in which recovery is managed across time
and multiple episodes of care.
2
Nine Year 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 9 years; over 80% completed within +/- 1 week
of target date.
Funding:
CSAT grant # T100664, contract # 270-97-7011
NIDA grant 1R01 DA15523
3
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 ,
Scott, Funk &
Foss ( 2005)
(n=1,271)
4
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) 5
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) 6
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) 7
Duration of Treatment Career
By Level of Internal Distress at Index TX
100%
90%
Internal Distress
High*
Moderate
Low
80%
Percent in Recovery
70%
60%
50%
40%
Note that it takes
several years to see
the difference
30%
20%
10%
0% 0
5
10
15
20
Years from first Tx to 1+ years abstinence
25
•p<.05
(High v low)
Source: Dennis et
al 2005 (n=1,271) 8
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery
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
9
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 Relapsing from Abstinence
+ times in treatment (1.21)
- Female (0.58)
+ homelessness (1.64)
- ASI legal composite (0.84)
+ number of arrests (1.12)
- # of sober friend (0.82)
- per 77 self help sessions (0.55)
10
Source: Scott, Dennis, & Foss (2005)
% Sustaining Abstinent through Year 8 .
Percent Sustaining Abstinence Through Year 8 by
Duration of Abstinence at Year 7
100%
90%
80%
70%
60%
50%
40%
Even after 3 to 7 years of
abstinence about 14% relapse
It takes a year
of abstinence
before less than
half relapse
86%
86%
3 to 5 years
(n=59; OR=11.2)
5+ years
(n=96; OR=11.2)
66%
36%
30%
20%
10%
0%
1 to 12 months
(n=157; OR=1.0)
1 to 3 years
(n=138; OR=3.4)
Duration of Abstinence at Year 7
Source: Dennis, Foss & Scott (2007)
11
Other Aspects of Recovery
1-3 Years:
1-12 Months:
3-5 Years: 5-8 Years:
by Duration
of
Decrease
in Abstinence of 8 Years
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%
% of Clean and
Sober Friens
80%
70%
% Days Worked
For Pay (of 22)
% Above
Poverty Line
60%
50%
40%
30%
20%
% Days of Psych
Prob (of 30 days)
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)
% Days of Illegal
Activity (of 30 days)
12
Source: Dennis, Foss & Scott (2007)
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)
Source: Scott, Dennis, & Funk (2008)
1-3 Years
(OR=1.61)
4-8 Years
(OR=0.84)
13
Other Predictors of Death
+
+
+
+
Pre-existing chronic illness (RR=1.87)
Age (RR=1.45)
Living on less than 50% of poverty line (RR=1.71)
Hospitalization during the 6 months prior to intake
(RR=1.26 per week)
+ Illegal activity for money during the 6 months prior to
intake (RR=1.14 per 30 days)
- Self Help Sessions attended first 6 months (RR=0.88 per
30 days)
- Years of abstinence (RR=0.83 per year)
• Weeks of treatment predicted weeks of self help and reduced
risk of death univariately
• Being in treatment at month six predicted self help, years of
abstinence, and reduced risk of death univariately
14
The Early Re-Intervention (ERI) Experiments
(Dennis & Scott)
Recruitment
Recruited 446 from Community Based
Treatment in Chicago in 2004 (93% of
eligible recruited)
Design
Random assignment to Recovery
Management Checkups (RMC) or control
Follow-Up
Quarterly for 4 years (95 to 97% per wave)
Data Sources
GAIN, CEST, CAI, Neo, CRI, Urine, Staff
logs
Publication
Dennis, Scott & Funk (2003); Scott, Dennis,
& Foss (2005); Dennis & Scott (2007); Scott
& Dennis, (under review); Riley, Scott, &
Dennis (2008)
15
Funding Source NIDA grant R37-DA11323
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
16
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)
=16.56, p <.0001
Days to Re-Admission (from 3 month interview)
17
Source: Scott & Dennis (under review)
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 (under review)
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
18
ERI: 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
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
19
(d=0.31)*
* p<.05
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
20
ERI 2: Average Quarterly Transitions over 3
years
Transition Tx to Recovery (vs. relapse)
- Freq. of Use (0.01) + Self Help Act. (1.22)
- Tx Resistance (0.85) + Wks Self Help (1.20)
In the
Community
Using
(75% stable)
10%
Transition to Tx (vs use)
- Tx Resistance (0.94)
+ Freq. of Use (3.74)
+ Desire for Help (1.15)
+ Wks of Self Help (1.14)
+ Self Help Act. (1.31)
+ Prior Wks of Tx (1.10)
+ RMC (2.00)
In Recovery
(58% stable)
25%
35%
In Treatment
(32% stable)
Source: Riley, Scott & Dennis, 2008
21
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, and may need several
additional episodes of care before they reach a point
of stable recovery.
• Yet over half do achieve recovery
• Recovery is broader than just abstinence
• The odds of getting to and staying in recovery can be
improved with proactive checkups and management.
22
Sources and Related Work
• 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., 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.
• 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.
• 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)
• Riley, B.B.,, Scott, C.K, & Dennis, M.L. (2008). The effect of recovery management checkups on transitions from substance use to
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 Angless, CA. www.caldar.org .
• Rush, B., Dennis, M.L., Scott, C.K, Castel, S., & Funk, R.R. (2008). The Interaction of Co-Occurring Mental Disorders and Recovery
Management Checkusp on Treatment Participation and Recovery.
• Scott, C. K., & Dennis, M. L. (under review). Results from Two Randomized Clinical Trials evaluating the impact of Quarterly
Recovery Management Checkups with Adult Chronic Substance Users. Addiction.
• Scott, C. K., Dennis, M. L., & Foss, M. A. (2005). Utilizing recovery management checkups to shorten the cycle of relapse, treatment
re-entry, and recovery. Drug and Alcohol Dependence, 78, 325-338.
• Scott, C. K., Dennis, M. L., & Funk, R.R. (2008). Predicting the relative risk of death over 9 years based on treatment completion and
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 .
• 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.
23