1. 1 Managing Substance Use Disorders (SUDS) as a Chronic Condition Michael L. Dennis, Ph.D. & Christy K Scott, Ph.D. Chestnut Health Systems 720 W. Chestnut, Bloomington, IL 61701, USA E-mail: mdennis@chestnut.org Presentation in the 4th Plenary Session: Life Cycle’s Impact on Service Delivery and on Policies at the 48 th International Council on Alcohol and Addictions Budapest, Hungary, 23 October 2005 This presentation was supported by funds and data from NIDA grant no. R37-DA11323 and 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 mdennis@chestnut.org or 309-820-3805. A copy of these slides will be posted at www.chestnut.org/li/postersmdennis@chestnut.orgwww.chestnut.org/li/posters.

2. 2 Abstract (Handouts Only) 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 better understanding subset of people with chronic substance use disorders, the course of these disorders, and how they can be better managed across time and multiple episodes of care. Data will be presented to help characterize chronic substance use disorders in terms of a) the dependence syndrome, b) addiction careers lasting several decades, c) multiple episodes of care over several years, d) cycling through periods of relapse, treatment admission/incarceration and recovery, and e) multiple co-occurring problems that make it difficult to sustain recovery. The presentation will then highlight the results of the Early Re- Intervention (ERI) experiments (n=448 and 446 adults) with quarterly recovery management checkups (RMC) that were designed to detect when people had relapsed, motivate them to return to treatment, help them get back into treatment, and make sure that they engage in treatment. Relative to people in a control group, those receiving RMC were significantly more likely to return to treatment sooner, received more treatment, have less quarters of being in need of treatment and to have better long term outcomes. In the second experiment, it will demonstrate that we were able to further improve outcomes by changing the staff level, adding transportation assistance and the engagement component, we were able achieve better outcomes sooner. (Supported by NIDA grant DA11323)

3. 3 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.Describing the prevalence and characteristics of this subset of people 2.the course of these disorders, and 3.the results of two experiments designed to improve the ways in which this condition is managed across time and multiple episodes of care.

4. 4 Definition of Chronic SUD While terms like substance use, abuse, dependence, and addiction are frequently used interchangeably, state regulators, accreditation programs, clinical providers and more recently clinical researchers have become increasingly consistent in how they define chronic substance use disorders. 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” and “hazardous use” respectively 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)

5. 5 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 et al forthcoming

6. 6 Problems Vary by Age Source: 2002 NSDUH and Dennis et al forthcoming 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

7. 7 Higher Severity is Associated with Higher Annual Cost to Society Per Person Source: 2002 NSDUH and Dennis et al forthcoming $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

8. 8 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).

9. 9 Multiple Co-occurring Problems Contribute to Chronicity 0% 20%40%60%80% 100% Health Distress Internal Disorders External Disorders Crime/Violence Criminal Justice System Involvement Dependent (n=1221) Other (n=385) 0% 20% 40%60%80% 100% Dependent (n=3135) Other (n=2617) Adolescents Adults Source: GAIN Coordinating Center Data Set Exception

10. 10 Substance Use Careers Last for Decades Percent in Recovery Years from first use to 1+ years abstinence 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)

11. 11 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+)

12. 12 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+)

13. 13 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)

14. 14 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% 13% 28% 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

15. 15 Source: Scott et al 2005 Predictors of Change Also Vary by Direction In the Community Using (53% stable) In Recovery (58% stable) 13% 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) 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)

16. 16 The Early Re-Intervention (ERI) Experiments 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 Scott & Dennis, under review (12 month findings) Funding Source NIDA grant R37-DA11323

17. 17 Sample Characteristics of ERI 1 & 2 Experiments 0% 20%40%60%80% 100% African American Age 30-49 Female Employed Dependence Prior Treatment Residential Treatment Other Mental Disorders Homeless Physical Health Problems ERI 1 (n=448) ERI 2 (n=446)

18. 18 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

19. 19 Modifications to RMC for ERI -2 included: Switch to on-site urine monitoring with immediate feedback to improve detection 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

20. 20 0% 20% 40% 60% 80% 100% Follow-up (96% avg) Needed Tx (45% avg) Attended Linkage (99% avg) Agreed to Tx Assessment (48% avg) Showed to Tx Assessment (42% avg) Showed to Tx (35% avg) Stayed in Tx 14+ days (60% avg) ERI 1 Max Avg Min Adherence to Recovery Management Checkup (RMC) Protocol in ERI 1 vs. 2 Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis, forthcoming) Generally averaged as well or better Quality assurance and transportation assistance reduced the variance Improved Screening ERI 2 Improved Retention

21. 21 % Readmitted (Months 4-12) Relative to Control clients, RMC clients were more likely to return to treatment Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scot & Dennis, forthcoming 30% 38% 22% 36% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% ERI 1 (d=+.17)TERI-2 (d=+.30)* 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% *p<.05 ERI 1 RMCERI 2 ControlERI 2 RMCERI 1 Control

22. 22 Mean Days of Treatment Received (months 4-12) RMC clients received more Total Days of Treatment Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming) ERI 1 RMCERI 2 ControlERI 2 RMCERI 1 Control

23. 23 % with any successive quarters in need of treatment RMC clients were less likely to have Successive Quarters in Need of Treatment Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming) ERI 1 RMCERI 2 ControlERI 2 RMCERI 1 Control

24. 24 In Need of Tx (using in community) at 12 months RMC clients were less likely to be in need of treatment at the end of 12 months Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming) Every Quarter this difference has been growing; Hence our plans to go out 4 years ERI 1 RMCERI 2 ControlERI 2 RMCERI 1 Control

25. 25 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)

26. 26 Reprise There is clearly a subset of people for whom substance use disorder are a chronic condition that last for many years, is expensive, and confounded with a wide range of other problems. Shifting to a recovery management paradigm requires a better understanding of how people cycle through relapse, incarceration, treatment and recovery While the natural cycle may take almost a decade and 3 to 4 episodes of care – it can be experimentally altered with more proactive early intervention protocols.

27. 27 Implications We need to 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 Need for changes in funding, licensure and accreditation to accommodate and encourage above

28. 28 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.http://www.DrugAbuseStatistics.SAMHSA.gov GAIN Coordinating Center Data Set (2005). Bloomington, IL: Chestnut Health Systems. See www.chestnut.org/li/gain.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 co- occurring 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., 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. 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. (forthcoming). A Replicable Model for Managing Addiction as a Chronic Condition using Quarterly Recovery Management Check-ups (RMC). Manuscript under review. 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. World Health Organization (WHO). (1999). The International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10). Geneva, Switzerland: World Health Organization. Retrieved from www.who.int/whosis/icd10/index.html. www.who.int/whosis/icd10/index.html