1. 1 Understanding and Managing The Recovery Cycle Michael L. Dennis, Ph.D. (with slides from) Christy K Scott, Ph.D. Mark D. Godley, Ph.D. Susan H. Godley, Rh.D. Chestnut Health Systems Bloomington and Chicago, IL 4/21/2008 presentation at Addiction Technology Transfer Center (ATTC) Network Meeting, April 21-22, 2008, Marriott Renaissance Baltimore Harbor Place Hotel Baltimore, Md. This presentation was supported by funds from NIDA grant no. R01 DA15523, R37-DA11323; NIAAA grant AA010368; and CSAT contract no. 270-07-0191. The opinions are those of the authors do not reflect official positions of the government. Please address comments or questions to the author at mdennis@chestnut.org or 309-820-3805.mdennis@chestnut.org.

2. 2 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 quantifying the chronic nature of substance disorders and how it relates to a broader understanding of recovery 2.The results of three experiments designed to improve the ways in which recovery is managed across time and multiple episodes of care.

3. 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% Source: 2002 NSDUH and Dennis & Scott in press

4. 4 Problems Vary by Age Source: 2002 NSDUH and Dennis & Scott in press 0 10 20 30 40 50 60 70 80 90 100 12-1314-1516-1718-2021-2930-3435-4950-64 65+ No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence NSDUH Age Groups Severity Category Adolescent Onset Remission Increasing rate of non- users

5. 5 Higher Severity is Associated with Higher Annual Cost to Society Per Person Source: 2002 NSDUH and Dennis & Scott in press $0 $231 $725 $406 $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 No Alcohol or Drug Use Light Alcohol Use Only Any Infrequent Drug Use Regular AOD Use Abuse Dependence Median (50 th percentile) $948 $1,613 $1,078 $1,309 $1,528 $3,058 Mean (95% CI) This includes people who are in recovery, elderly, or do not use because of health problems Higher Costs

6. 6 The Majority Stay in Tx Less than 90 days 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. 52 42 20 33 0 30 60 90 OutpatientIntensive Outpatient Short Term Residential Long Term Residential Level of Care Median Length of Stay in Days Half are gone within 8 weeks, less than 25% stay the 90 days recommended by NIDA researchers

7. 7 Less Than Half Are Positively Discharged 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. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% OutpatientIntensive Outpatient Short Term Residential Long Term Residential Level of Care Discharge Status Other Terminated Dropped out Completed Transferred Less than 10% are transferred

8. 8 Multiple Co-occurring Problems are Correlated with Severity and Contribute to Chronicity 0% 20%40%60%80% 100% Health Distress Internal Disorders External Disorders Crime/Violence Criminal Justice System Involvement Dependent (n=1221) Abuse/Other (n=385) 0% 20% 40%60%80% 100% Dependent (n=3135) Abuse/Other (n=2617) Adolescents Adults Source: GAIN Coordinating Center Data Set Adolescents More likely to have externalizing disorders Adults more likely to have internalizing disorders[

9. 9 Pathways to Recovery Study (Scott & Dennis) Recruitment: 1995 to 1997 Sample: 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 (Scott & Dennis)

10. 10 Pathways to Recovery Sample Characteristics 0% 20%40%60%80% 100% African American Age 30-49 Female Current CJ Involved Past Year Dependence Prior Treatment Residential Treatment Other Mental Disorders Homeless Physical Health Problems The sample is predominately African American, Middle Age, Female, With Dependence, and Prior Treatment

11. 11 Substance Use Careers Last for Decades Percent in Recovery 302520151050 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Median duration of 27 years (IQR: 18 to 30+) Source: Dennis et al 2005 (n=1,271) Years from first use to 1+ years abstinence

12. 12 Substance Use Careers are Longer, the Younger the Age of First Use Percent in Recovery Years from first use to 1+ years abstinence 302520151050 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Dennis et al 2005 (n=1,271) under 15* 21+ 15-20* Age of 1 st Use Groups * p<.05 (different from 21+)

13. 13 Substance Use Careers are Shorter the Sooner People get to Treatment Percent in Recovery Years from first use to 1+ years abstinence 302520151050 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Dennis et al 2005 (n=1,271) 20+ 0-9* 10-19* Years to 1 st Tx Groups * p<.05 (different from 20+)

14. 14 It Takes Decades and Multiple Episodes of Treatment Years from first Tx to 1+ years abstinence 2520151050 Median duration of 9 years (IQR: 3 to 23) and 3 to 4 episodes of care Percent in Recovery 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Dennis et al 2005 (n=1,271)

15. 15 The Cyclical Course of Relapse, Incarceration, Treatment and Recovery In the Community Using (53% stable) In Treatment (21% stable) In Recovery (58% stable) Incarcerated (37% stable) 6% 28% 13% 30% 8% 25% 31% 4% 44% 7% 29% 7% Treatment is the most likely path to recovery P not the same in both directions Source: Scott et al 2005 Over half change status annually

16. 16 Source: Scott et al 2005 Predictors of Change Also Vary by Direction In the Community Using (53% stable) In Recovery (58% stable) 28% 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) 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)

17. 17 Percent Sustaining Abstinence Through Year 8 by Duration of Abstinence at Year 7 36% 66% 86% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 to 12 months (n=157; OR=1.0) 1 to 3 years (n=138; OR=3.4) 3 to 5 years (n=59; OR=11.2) 5+ years (n=96; OR=11.2) Duration of Abstinence at Year 7 % Sustaining Abstinent through Year 8. It takes a year of abstinence before less than half relapse Even after 3 to 7 years of abstinence about 14% relapse Source: Dennis, Foss & Scott (2007)

18. 18 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Using (N=661) 1 to 12 ms (N=232) 1 to 3 yrs (N=127) 3 to 5 yrs (N=65) 5 to 8 yrs (N=77) % Days of Psych Prob (of 30 days) % Above Poverty Line % Days Worked For Pay (of 22) % of Clean and Sober Friens % Days of Illegal Activity (of 30 days ) Other Aspects of Recovery by Duration of Abstinence of 8 Years 1-12 Months: Immediate increase in clean and sober friend 1-3 Years: Decrease in Illegal Activity; Increase in Psych Problems 3-5 Years: Improved Vocational and Financial Status 5-8 Years: Improved Psychological Status Source: Dennis, Foss & Scott (2007)

19. 19 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. “Recovery” is broader than abstinence and often takes several years after initial abstinence

20. 20 The Early Re-Intervention (ERI) Experiments (Dennis & Scott) ERI 1ERI 2 RecruitmentRecruited 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) DesignRandom assignment to Recovery Management Checkups (RMC) or control Follow-UpQuarterly for 2 years (95-97% per wave) Quarterly for 4 years (95 to 97% per wave) Data SourcesGAIN, CEST, Urine, Salvia Staff logs GAIN, CEST, CAI, Neo, CRI, Urine, Staff logs PublicationDennis, Scott & Funk 2003; Scott, Dennis & Foss, 2005 Dennis & Scott (in press); Scott & Dennis, (under review) Funding Source NIDA grant R37-DA11323

21. 21 Sample Characteristics of ERI-1 & -2 Experiments 0% 20%40%60%80% 100% African American Age 30-49 Female Current CJ Involved Past Year Dependence Prior Treatment Residential Treatment Other Mental Disorders Homeless Physical Health Problems ERI 1 (n=448) ERI 2 (n=446)

22. 22 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

23. 23 Impact of On-site Urine On False Negative Urines 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% OpiatesMarijuanaCocaineAny Drug Tested ERI 1ERI 2 At 24 months FN were at 19% for any drug Introducing the new protocol in ERI 2 dropped the 24 month FN rate to 3%

24. 24 RMC Protocol Adherence Rate by Experiment 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Follow-up Interview (93 vs. 96%) d=0.18 Treatment Need (30 vs. 44%) d=0.31* Linkage Attendance (75 vs. 99%) d=1.45* Agreed to Assessment (44 vs. 45%) d=0.02 Showed to Assessment (30 vs. 42%) d=0.26* Showed to Treatment (25 vs. 30%) d=0.18* Treatment Engagement (39 vs. 58%) d=0.43* Range of rates by quarter * P(H: RMC1=RMC2)<.05 ERI-1 ERI-2 ERI 2 Generally averaged as well or better than ERI 1 Improved Screening Improved Tx Engagement Quality assurance and transportation assistance reduced the variance

25. 25 ERI-1 Time to Treatment Re-Entry 0%0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 090180270 360450540630 Days to Re-Admission (from 3 month interview) Percent Readmitted 1+ Times 60% ERI-1 RMC* (n=221) 51% ERI-1 OM (n=224) *Cohen's d=+0.22 Wilcoxon-Gehen Statistic (df=1) =5.15, p <.05 630-403 = -200 days Revisions to the protocol

26. 26 ERI-2 Time to Treatment Re-Entry 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 090 180 270 360450540 630 Days to Re-Admission (from 3 month interview) Percent Readmitted 1+ Times 55% ERI-2 RMC* (n=221) 37% ERI-2 OM (n=224) *Cohen's d=+0.41 Wilcoxon-Gehen Statistic (df=1) =16.56, p <.0001 630-246 = -384 days The size of the effect is growing every quarter

27. 27 ERI-2: Impact on Outcomes at 45 Months 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Re-entered Treatment (d=0.22)* of 14 Subsequent Quarters in Need (d= 0.26) * of 1260 Days Abstinent (d= 0.26)*(d= -0.32)* Still in need of Tx at Mon 45 (d= -0.22) * Percentage OMRMC * p<.05 55% 41% 67% 50% 56% 38% Fewer Seq. Quarters in Need 74% More days of abstinent of 180 Days of Treatment 71% 61% RMC Increased Treatment Participation 47% Less likely to be in Need at 45m

28. 28 Source: ERI experiments (Scott, Dennis, & Foss, 2005) Impact on Primary Pathways to Recovery (incarceration not shown) In the Communityy Using (71% stable) In Treatment (35% stable) In Recovery (76% stable) 27% 5% 8% 33% 18% 17% Transition to Tx - Freq. of Use (0.7) + Prob. Orient. (1.4) + Desire for Help (1.6) + RMC (3.22) Again the Probability of Entering Recovery is Higher from Treatment 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) 32% Changed Status in an Average Quarter

29. 29 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 ERI 2 also demonstrated the value of on-site proactive urine testing versus the traditional practice of sending off urine for post interview testing

30. 30 Assertive Continuing Care (ACC) Experiment (Godley et al) Recruitment: 1998 to 2000 Sample: 183 adolescents admitted to Chestnut’s residential substance abuse treatment in central Illinois Substance Dep.:Marijuana (87%), alcohol (54%), cocaine (15%), other substance (14%) Levels of Care: Treated for 30-90 days inpatient, then discharged to outpatient continuing care treatment Instrument:Global Appraisal of Individual Needs (GAIN) and other measures Design:Random assignment to usual continuing care (UCC) or “assertive continuing care” (ACC) Follow-up:Over 90% follow-up 3, 6, & 9 months post discharge Funding: NIAAA grant 1R01 AA0103685 (Godley et al)

31. 31 Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0102030405060708090 Days after Residential (capped at 90) Percent of Clients Cont. Care Admis. (36%) Relapse Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17)

32. 32 ACC Experiment Sample Characteristics 0% 20%40%60%80% 100% Caucasian Age 15-16 Male Current CJ Involved Past Year Dependence Prior SA Treatment Prior MH Treatment Other Mental Disorders 4 to 12 weeks in Res. SA Tx Completed Single Parent Source: Godley et al 2002, 2007

33. 33 ACC Enhancements Continue to participate in UCC Home Visits Sessions for adolescent, parents, and together Sessions based on ACRA 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)

34. 34 Assertive Continuing Care (ACC) Hypotheses Assertive Continuin g Care General Continuin g Care Adherence Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA) Early Abstinence GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence Sustained Abstinence Early abstinence will be associated with higher rates of long term abstinence.

35. 35 ACC Improved Adherence Source: Godley et al 2002, 2007 0% 10% 20% 30% 40%50%60%70%80% WeeklyTx Weekly 12 step meetings Regular urine tests Contact w/probation/school Follow up on referrals* ACC * p<.05 90% 100% Relapse prevention* Communication skills training* Problem solving component* Meet with parents 1-2x month* Weekly telephone contact* Referrals to other services* Discuss probation/school compliance* Adherence: Meets 7/12 criteria* UCC

36. 36 GCCA Improved Early (0-3 mon.) Abstinence Source: Godley et al 2002, 2007 24% 36% 38% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=2.16*)Alcohol (OR=1.94*) Marijuana (OR=1.98*) Low (0-6/12) GCCA 43% 55% High (7-12/12) GCCA * p<.05

37. 37 Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence Source: Godley et al 2002, 2007 19% 22% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any AOD (OR=11.16*)Alcohol (OR=5.47*) Marijuana (OR=11.15*) Early(0-3 mon.) Relapse 69% 59% 73% Early (0-3 mon.) Abstainer * p<.05

38. 38 Post script on ACC The ACC intervention improved adolescent adherence to the continuing care expectations of both residential and outpatient staff; doing so improved the rates of short term abstinence and, consequently, long term abstinence. Despite these gains, many adolescents in ACC (and more in UCC) did not adhere to continuing care plans. The ACC manual and main findings have been published A-CC is being replicated in over 30 sites as part of CSAT’s Assertive Adolescent Family Therapy (AAFT) program and CSAT’s Adolescent Residential Treatment (ART) program. A second ACC experiment is currently under way to evaluate whether providing contingency management will further improve outcomes.

39. 39 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. Multiple co-occurring individual and environmental problems are the norm and also need to be addressed Yet over half do make it to recovery and the odds of getting to and staying in recovery can be improved with proactive management.

40. 40 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.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.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) 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., 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.