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, R37-DA11323 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 mdennis@chestnut.org or 309-820-3805. . Thank you… I would like to start by acknowledging that this presentation builds on a series of studies and papers the Christy Scott, Mark Godley, Susan Godley and I have done… as well as data from the several large community and clinical epidemiological data bases made available to the public by the U.S. Government. Also note that i have posted an electronic copy of this presentation at www.chestnut.org/li/posters

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

Nine Year 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 9 years; over 80% completed within +/- 1 week of target date. Funding: CSAT grant # T100664, contract # 270-97-7011 NIDA grant 1R01 DA15523 Purpose: Substance use disorders are chronic relapsing conditions

Substance Use Careers Last for Decades 100% 90% 80% Percent in Recovery 70% Median duration of 27 years (IQR: 18 to 30+) 60% Years from first use to 1+ years abstinence 50% 40% 30% Using data from a clinical sample of 1,271 people in Dr. Scott’s 9 year pathways to recovery study, this figure presents a survival analysis estimating the time from first use to 1 or more years of sobriety. The line shows the percent with 1 or more years of abstinence. 1- The median duration was 27 years – with an inter-quartile range (i.e., middle 50%) of 18 to over 30 years. For Reference only… We stopped at that point due to censoring in the data due limiting us to 100 or less people and due to 2.6% who had died. We are currently working to extend this another 5 to 10 years and also look at the impact of recovery on the likelihood of death. 20% 10% 0% Source: Dennis , Scott, Funk & Foss ( 2005) (n=1,271) 5 10 15 20 25 30

Source: Dennis et al 2005 (n=1,271) Substance Use Careers are Longer, the Younger the Age of First Use 100% 90% 21+ 80% Percent in Recovery 15-20* Age of 1st Use Groups 70% 60% Years from first use to 1+ years abstinence under 15* 50% 40% 30% Substance use careers are longer the earlier the age of first use --- 20% * p<.05 (different from 21+) 10% 0% 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

Source: Dennis et al 2005 (n=1,271) Substance Use Careers are Shorter the Sooner People get to Treatment 100% 0-9* 90% 80% 10-19* Percent in Recovery Years to 1st Tx Groups 70% 60% Years from first use to 1+ years abstinence 50% 40% 20+ 30% 1- However, entering treatment in the first decade of use was associated with reducing the lifetime substance use career by over half. It does not take long to realize that the potential saving in societal costs justifies more research on to improve participation in and the effectiveness of adolescent substance abuse treatment. 20% 10% * p<.05 (different from 20+) 0% 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

Multiple Episodes of Treatment 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 Years from first Tx to 1+ years abstinence 60% 50% 40% 30% Note that one episode of treatment is rarely sufficient once someone has a chronic substance use disorder with multiple co-occurring problems. This figure shows the time from 1st treatment to 1+ years of abstinence, the median was 9 years with an inter-quartile range of 3 to 23 years. Moreover the average person did not have 1+ years of abstinence until then had been in treatment 3 to 4 times. The traditional acute care model focusing on 1-12 sessions or even 90 days of treatment and 6 month outcomes are simply not sufficient for treating or studying the treatment of this kind of chronic substance use disorders. 20% 10% 0% 5 10 15 20 25 Source: Dennis et al 2005 (n=1,271)

Duration of Treatment Career By Level of Internal Distress at Index TX 100% Internal Distress 90% High* Moderate 80% Percent in Recovery Low 70% Years from first Tx to 1+ years abstinence 60% 50% 40% Note that it takes several years to see the difference 30% Note that one episode of treatment is rarely sufficient once someone has a chronic substance use disorder with multiple co-occurring problems. This figure shows the time from 1st treatment to 1+ years of abstinence, the median was 9 years with an inter-quartile range of 3 to 23 years. Moreover the average person did not have 1+ years of abstinence until then had been in treatment 3 to 4 times. The traditional acute care model focusing on 1-12 sessions or even 90 days of treatment and 6 month outcomes are simply not sufficient for treating or studying the treatment of this kind of chronic substance use disorders. 20% 10% p<.05 (High v low) 0% 5 10 15 20 25 Source: Dennis et al 2005 (n=1,271)

Over half change status annually 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% 28% 13% 7% 29% 30% 8% 25% Treatment is the most likely path to recovery 31% 4% 44% In the Community In Recovery Using (58% stable) (53% stable) To shift to a chronic condition management paradigm it is necessary to start by recognizing that most people are typically cycling through multiple periods of being in the community using, incarceration, treatment and being in the community in recovery for a month or more. The circles in this figure show the average percent staying in each condition between two annual interviews for this same large sample. 45% stayed in the same status for 12 months and 55% changed. 1,2,3,4 ---- these arrows show the percent moving along each pathway from one state to another. 5- Notice that the percentages are not the same in both directions. 6- Also notice that the probability of moving from the three states on the left to recovery on the right are not the same --- with treatment being the most likely pathway to recovery over a 12 month period. In Treatment (21% stable) Source: Scott, Dennis, & Foss (2005)

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 28% Community In Recovery Using (58% stable) 29% (53% stable) The predictors of change also vary by the direction of movement. 1- The probability of transitioning from using to abstinence was inversely related to mental distress and ASI legal composite score and directly related to being older at first use, being homeless, having more sober friends, and the amount of treatment received during the year. 2- The probability of relapsing from abstinence was directly related to the lifetime number of treatment episodes and homelessness and inversely related to being female, the number of arrests, ASI legal composite score, # of sober friends, and participation in self help sessions. Notice that some things like legal involvement work to hold a person in either condition while others like homeless work to change the condition. In contrast, the amount of treatment is one of the better predictors of who will transition to recovery while self help participation is the better predictor of who stays there. The question arises whether increasing early treatment participation would hasten the transition to recovery. 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) Source: Scott, Dennis, & Foss (2005)

Percent Sustaining Abstinence Through Year 8 by Duration of Abstinence at Year 7 100% Even after 3 to 7 years of abstinence about 14% relapse . 86% 86% 90% 80% It takes a year of abstinence before less than half relapse 70% 66% 60% % Sustaining Abstinent through Year 8 50% 36% 40% 30% 20% A key question that is often asked is how long someone is at risk of relapse. This figure shows the odds of sustaining relapsed from year 7 to year 8 based on the duration of abstinence. 10% 0% 1 to 12 months 1 to 3 years 3 to 5 years 5+ years (n=157; OR=1.0) (n=138; OR=3.4) (n=59; OR=11.2) (n=96; OR=11.2) Duration of Abstinence at Year 7 Source: Dennis, Foss & Scott (2007)

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 100% % of Clean and Sober Friens 90% 80% 70% 60% % Days Worked For Pay (of 22) 50% % Above Poverty Line 40% 30% This figure classifies people at year 8 of the study based on how long they have been abstinent (if at all) to examine how the duration of abstinence is related to other aspects of recovery 20% % Days of Illegal Activity (of 30 days) % 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) Source: Dennis, Foss & Scott (2007)

Death Rate by Years of Abstinence The Risk of Death goes down with years of sustained abstinence 4.5% 11.9% 7.1% 3.8% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 14% 15% Household (OR=1.00) Less than 1 (OR=2.87) 1 - 3 Years (OR=1.61) 4 8 Years (OR=0.84) Users/ Early Abstainers 2.87 times more likely to die in the next year It takes 4 or more years of abstinence for risk to get down to community levels A key question that is often asked is how long someone is at risk of relapse. This figure shows the odds of sustaining relapsed from year 7 to year 8 based on the duration of abstinence. Source: Scott, Dennis, & Funk (2008)

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) Of all the variables in Table 1, the only two significant predictors of the duration of abstinence at the last wave are the days of self-help at 6 months (b=.007, p=.000) and being in treatment at month 6 (b=.429, p=.000). The days of self help attendance in the first six months were significantly lower for people with a history of chronic illness, living below 50% of the poverty line, and with more years of regular heroin use. They were significantly higher for people with more years of regular use, those having unprotected sex with multiple partners, and those still in treatment at month 6. 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

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) In the final part of this presentation I want to tell you about two experiments in which we are trying to alter SUD trajectories through early intervention. In the first ERI experiment we recruited 448 adults from the largest community based treatment provider in Chicago in 2000. We only excluded people who were from outside of Chicago, headed to prison for the study period, did not speak English or Spanish, or who were too cognitively impaired to give informed consent. Of those who were eligible, 84% agreed to participant and were randomly assigned to either a Recovery Management Checkups or a control group. Both groups were re-interviewed quarterly for 2 years – with 95 to 97% follow-up per wave. The Data sources included the Global Appraisal of Individual Needs (GAIN), motivational scales from TCU Client Evaluation of Self and Treatment (CEST), Urine & Salvia tests and staff logs. In the second ERI experiment we recruited 446 adults from the same community based program 4 years later, used the same exclusion rules, and achieved 93% participation. Again we randomly assigned them to RMC or a control group, but this time for four years. Here I will present findings from the first 12 months – with 95 to 97% follow-up per wave. In addition to the earlier measures, this time we also collected additional scales on treatment process from NDRI’s Client Assessment Interview, personality measures from the NEO and the Moos Coping Response Inventory. 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

ERI-2 Time to Treatment Re-Entry 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% The size of the effect is growing every quarter 630-246 = -384 days Percent Readmitted 1+ Times 55% ERI-2 RMC* (n=221) 37% ERI-2 OM (n=224) *Cohen's d=+0.41 Wilcoxon-Gehen 0% 90 180 270 360 450 540 630 Statistic (df=1) =16.56, p <.0001 Days to Re-Admission (from 3 month interview) Source: Scott & Dennis (under review)

ERI-2: Impact on Outcomes at 45 Months 74% More days of abstinent 100% 71% 61% RMC Increased Treatment Participation OM RMC 90% 47% Less likely to be in Need at 45m 80% 38% Fewer Seq. Quarters in Need 70% 67% 56% 60% 55% 50% Percentage 50% 41% 40% 30% 20% What this figures shows is the total number of days --- green RMC, red control….. Keep in mind that the control group did not get any help. The right….literature 10% 0% Re-entered of 180 Days of 1260 Days of 14 Subsequent Still in need of Tx at Mon 45 Treatment of Treatment Abstinent Quarters in Need (d=0.22)* (d= 0.26) * (d= 0.26)* (d= -0.32)* (d= -0.22) * Source: Scott & Dennis (under review) * p<.05

ERI: Impact Treatment Re-entry by Comorbidity and Condition RMC’s Impact on Treatment Participation was robust across levels of Comorbidity Returning to treatment varied by Comorbidity 100% OM RMC 90% 80% 70% 62% 63% 49% 60% 53% Percentage 47% 50% 40% 33% 30% 20% What this figures shows is the total number of days --- green RMC, red control….. Keep in mind that the control group did not get any help. The right….literature 10% 0% Substance Use Disorder (SUD) (d=0.23)* Substance Use + Internalizing Disorders (d=0.38)* Substance Use + Internalizing + Externalizing Disorders (d=0.31)* Source: Rush, Dennis, Scott, Castel, & Funk (2008) * p<.05

34% Changed Status in an Average Quarter ERI 2: Average Quarterly Transitions over 3 years 34% Changed Status in an Average Quarter Incarcerated (56% stable) 4% 10% 6% 24% 3% 23% 8% 13% Again the Probability of Entering Recovery is Higher from Treatment 35% 7% 25% In the Community In Recovery Using (58% stable) (75% stable) To shift to a chronic condition management paradigm it is necessary to start by recognizing that most people are typically cycling through multiple periods of being in the community using, incarceration, treatment and being in the community in recovery for a month or more. The circles in this figure show the average percent staying in each condition between two annual interviews for this same large sample. 45% stayed in the same status for 12 months and 55% changed. 1,2,3,4 ---- these arrows show the percent moving along each pathway from one state to another. 5- Notice that the percentages are not the same in both directions. 6- Also notice that the probability of moving from the three states on the left to recovery on the right are not the same --- with treatment being the most likely pathway to recovery over a 12 month period. In Treatment (32% stable) Source: Riley, Scott & Dennis, 2008

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 In Recovery Using (58% stable) (75% stable) To shift to a chronic condition management paradigm it is necessary to start by recognizing that most people are typically cycling through multiple periods of being in the community using, incarceration, treatment and being in the community in recovery for a month or more. The circles in this figure show the average percent staying in each condition between two annual interviews for this same large sample. 45% stayed in the same status for 12 months and 55% changed. 1,2,3,4 ---- these arrows show the percent moving along each pathway from one state to another. 5- Notice that the percentages are not the same in both directions. 6- Also notice that the probability of moving from the three states on the left to recovery on the right are not the same --- with treatment being the most likely pathway to recovery over a 12 month period. 35% 25% 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 Treatment (32% stable) Source: Riley, Scott & Dennis, 2008

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.

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.