1. 1 Research on Understanding and Managing Addiction as a Chronic Condition Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation at the 53rd International Council on Alcohol and Addiction (ICAA) and Centros de Integración Juvenil (CIJ) Conference on Dependencies "New Challenges - New Solutions", November 3 to 6, 2010, Cancun, Mexico. This presentation was supported by funds and data from NIDA grants no. R01 DA15523 (C.Scott), R37- DA11323 (M.Dennis), CSAT contract no. 270-07-0191 (M.Dennis) and several other authors/studies. It is available electronically at www.chestnut.org/li/posters. The opinions are those of the author and do not reflect official positions of the government. Please address comments or questionswww.chestnut.org/li/posters to the author at mdennis@chestnut.org or 309-451-7801.mdennis@chestnut.org.p

2. 2 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

3. 3 Normal 10 days of abstinence 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. Prolonged Substance Use Injures The Brain: Healing Takes Time Normal levels of brain activity in PET scans show up in yellow to red After 100 days of abstinence, we can see brain activity “starting” to recover Reduced brain activity after regular use can be seen even after 10 days of abstinence

4. 4 Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front

5. 5 Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20 Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000 0 10 20 30 40 50 60 70 80 90 100 12-1314-1516-1718-2021-2930-3435-4950-64 65+ Other drug or heavy alcohol use in the past year Alcohol or Drug Use (AOD) Abuse or Dependence in the past year Age Severity Category Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Percentage People with drug dependence die an average of 22.5 years sooner than those without a diagnosis

6. 6 Substance Use Disorders are Common, But Treatment Participation Rates Are Low: United States (US) Source: OAS, 2009 – 2006, 2007, and 2008 NSDUH Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Few Get Treatment: 1 in 19 adolescents, 1 in 21 young adults, 1 in 12 adults Much of the private funding is limited to 30 days or less and authorized day by day or week by week

7. 7 People Entering Publicly Funded Treatment Generally Use For Decades P e r c e n t s t i l l u s i n g Years from first use to 1+ years of abstinence 302520151050 Source: Dennis et al., 2005 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% It takes 27 years before half reach 1 or more years of abstinence or die

8. 8 Percent still using Years from first use to 1+ years of abstinence under 15* 21+ 15-20 Age of First Use 302520151050 Source: Dennis et al., 2005 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 60% longer The Younger They Start, The Longer They Use * p<.05

9. 9 Percent still using Years from first use to 1+ years of abstinence Years to first Treatment Admission* 302520151050 Source: Dennis et al., 2005 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20 or more years 0 to 9 years 10 to 19 years 57% quicker The Sooner They Get To Treatment, The Quicker They Get To Abstinence * p<.05

10. 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. 11 * p<.05 The Likelihood of Sustaining Abstinence Another Year Grows Over Time 36% 66% 86% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1 to 12 months1 to 3 years4 to 7 years Duration of Abstinence* % Sustaining Abstinence Another Year. After 1 to 3 years of abstinence, 2/3rds will make it another year After 4 years of abstinence, about 86% will make it another year Source: Dennis, Foss & Scott (2007) Only a third of people with 1 to 12 months of abstinence will sustain it another year But even after 7 years of abstinence, about 14% relapse each year

12. 12 Source: Dennis, Foss & Scott (2007) What does recovery look like on average? Duration of Abstinence 1-12 Months 1-3 Years 4-7 Years 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 Virtual elimination of illegal activity and illegal income Better housing and living situations Increasing employment and income 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

13. 13 Sustained Abstinence Also Reduces The Risk of Death* Source: Scott, Dennis, Laudet, Funk & Simeone (in press) - Users/Early Abstainers more likely to die in the next 12 months The Risk of Death goes down with years of sustained abstinence It takes 4 or more years of abstinence for risk to get down to community levels (Matched on Gender, Race & Age) Deaths in the next 12 months * p<.05

14. 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. 15 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

16. 16 ERI-2 Time to Treatment Re-Entry at Year 4 Percent Readmitted 1+ Times Wilcoxon-Gehen statistic (df=1) = 28.60, p<.001 OR=3.1, p<.05 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0369121518212427303336394245 Months from 1st Follow-up In Need for Treatment, Time from relapse to readmission reduce by 78% (45-13 = -32 months; d=-.41) 74% ERI-2 RMC* (n=198) 48% ERI-2 OM (n=195) RMC increases the odds of re-entering treatment over 4 years by 3.1 Source: Scott & Dennis (2009); Dennis & Scott (under review) The size of the effect is growing every quarter

17. 17 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 Source: Scott & Dennis (2009); Dennis & Scott (under review)

18. 18 Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 Cost of Substance Abuse Treatment Episode $22,000 / year to incarcerate an adult $30,000/ child-year in foster care $70,000/year to keep a child in detention $750 per night in Detox $1,115 per night in hospital $13,000 per week in intensive care for premature baby $27,000 per robbery $67,000 per assault

19. 19 Investing in Treatment has a Positive Annual Return on Investment (ROI) Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested Treatment drug courts have an average ROI of $2.14 to $2.71 per dollar invested Source: Bhati et al., (2008); Ettner et al., (2006) This also means that for every dollar treatment is cut, we lose more money than we saved.

20. 20 Summary Points Addiction can be a chronic condition with high costs to the individual and society Getting people to 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

21. 21 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. Capriccioso, R. (2004). Foster care: No cure for mental illness. Connect for Kids. Accessed on 6/3/09 from http://www.connectforkids.org/node/571 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., 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 (under review). Four-year outcomes from the Early Re-Intervention Experiment (ERI) with Recovery Management Checkups (RMC). Normal, IL: Chestnut Health Systems. 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. Ettner, S.L., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., & Hser, Y.I. (2006). Benefit Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment Pay for Itself?. Health Services Research, 41(1), 192-213. French, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates of cost bands for program assessment and reimbursement. Journal of Substance Abuse Treatment, 35, 462-469 Neumark, Y.D., Van Etten, M.L., & Anthony, J.C. (2000). Drug dependence and death: Survival analysis of the Baltimore ECA sample from 1981 to 1995. Substance Use and Misuse, 35, 313-327. Office of Applied Studies (2006). Results from the 2005 National Survey on Drug Use and Health: National Findings Rockville, MD: Substance Abuse and Mental Health Services Administration. http://www.oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm#7.3.1 http://www.oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm#7.3.1 Scott, C. K., & Dennis, M. L. (2009). Results from Two Randomized Clinical Trials evaluating the impact of Quarterly Recovery Management Checkups with Adult Chronic Substance Users. Addiction, 104, 959-971. Scott, C. K., & Dennis, M. L. (in press). Recovery management checkups with adult chronic substance users. In Kelly, J.F., and White, W.L. (Eds), Addiction Recovery Management: Theory, Research, and Practice. New York, NY: Springer Scott, C. K., Dennis, M. L., Laudet, A., Funk R. & Simeone, R., & (in press). Surviving Drug Addiction: Do treatment and abstinence reduce mortality? American Journal of Public Health. 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. Volkow N.D., Fowler J.S., Wang G-J., Hitzemann R., Logan J., Schlyer D., Dewey 5., Wolf A.P. (1993). Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177. Volkow, N.D., Hitzemann R., Wang C-I., Fowler I.S., Wolf A.P., Dewey S.L. (1992). Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190.