Transcript Preliminary data from the Persistent Effects of Treatment

Understanding and Managing
The Recovery Cycle
Michael L. Dennis, Ph.D.
and Christy K Scott, Ph.D.
Chestnut Health Systems
720 W. Chestnut,
Bloomington, IL 61701, USA
E-mail: [email protected]
Presentation at the Second Betty Ford Institute (BFI) Conference Extending the
Benefits of Addiction Treatment: Practical Strategies for Continuing Care and
Recovery. This presentation was supported by funds from NIDA grant no. R37DA11323, and R01 DA15523. The opinions are those of the authors do not reflect
official positions of the government or BFI. Please address comments or questions to
the author at [email protected] or 309-820-3805. A copy of these slides will be
posted at www.chestnut.org/li/posters and the conference website
.
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. The results of a 9 year longitudinal study to
quantifying 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
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 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)
3
100%
80%
60%
40%
20%
0%
Pathways to Recovery Sample Characteristics
African American
Age 30-49
Female
Current CJ Involved
Past Year Dependence
Prior Treatment
Residential Treatment
Other Mental Disorders
Homeless
Physical Health Problems
4
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 et
al 2005 (n=1,271) 5
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) 6
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)
8%
13%
28%
In Recovery
(58% stable)
29%
4%
44%
31%
In Treatment
(21% stable)
Source: Scott et al 2005
7%
Treatment is the
most likely path
to recovery
7
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)
13%
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)
Source: Scott et al 2005
8
% 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 (in press)
9
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)
10
Source: Dennis, Foss & Scott (in press)
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
11
The Early Re-Intervention (ERI) Experiments
(Dennis & Scott)
ERI 1
ERI 2
Recruitment
Recruited 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)
Design
Random assignment to
Recovery Management
Checkups (RMC) or control
Random assignment to
Recovery Management
Checkups (RMC) or control
Follow-Up
Quarterly for 2 years (95-97% Quarterly for 4 years (95 to
per wave)
97% per wave)
Data Sources
GAIN, CEST, Urine, Salvia
Staff logs
GAIN, CEST, CAI, Neo, CRI,
Urine, Staff logs
Publication
Dennis, Scott & Funk 2003;
Scott, Dennis & Foss, 2005
Dennis & Scott (in press);
Scott & Dennis, (under
review)
12
Funding Source NIDA grant R37-DA11323
100%
80%
60%
40%
20%
0%
Sample Characteristics of ERI-1 & -2 Experiments
African American
Age 30-49
Female
Current CJ Involved
Past Year Dependence
Prior Treatment
Residential Treatment
Other Mental Disorders
Homeless
ERI 1 (n=448)
Physical Health Problems
ERI 2 (n=446)
13
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
14
RMC Protocol Adherence Rate by Experiment
100%
Quality
andaveraged
transportation
ERI assurance
2 Generally
as
assistance
the variance
well or reduced
better than
ERI 1
90%
80%
70%
60%
Improved
Screening
50%
40%
Improved
Tx
Engagement
30%
20%
10%
0%
Follow-up Treatment
Need
Interview
(93 vs. 96%)
d=0.18
(30 vs. 44%)
d=0.31*
ERI-1
ERI-2
<-Average->
Linkage
Agreed to Showed to Showed to Treatment
Attendance Assessment Assessment Treatment Engagement
(75 vs. 99%)
d=1.45*
(44 vs. 45%)
d=0.02
(30 vs. 42%)
d=0.26*
Range of rates by quarter
(25 vs. 30%)
d=0.18*
(39 vs. 58%)
d=0.43*
* P(H: RMC1=RMC2)<.05
15
ERI-1 Time to Treatment Re-Entry
100%
Percent Readmitted 1+ Times
90%
80%
630-403 = -200 days
70%
60% ERI-1 RMC*
(n=221)
51% ERI-1 OM
(n=224)
60%
50%
40%
30%
20%
Revisions to
the protocol
10%
0
% 0
90
180
270
360
450
540
*Cohen's d=+0.22
Wilcoxon-Gehen
Statistic (df=1)
630
=5.15, p <.05
Days to Re-Admission (from 3 month interview)
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
ERI-1: Impact on Outcomes
100%
90%
80%
Months 4-24
No effect on Abstinence/Symptoms
79% 79%
70%
Percentage
Final Interview
60%
RMC
Broke the
Run
80% 79%
OM
RMC
Less Likely to be in
Need of Treatment
44%
50%
40%
34%
33%
27%
30%
21% 21%
20%
10%
0%
of 630 Days
Abstinent
(d=0.04)
of 7 Subsequent
Quarters in Need
(d= -0.19) *
of 90 Days
Abstinent
(d= -0.05)
of 11 Sx of
Abuse/Dependence
(d=-0.02)
Still in need
of Tx
(d= -0.21) *
* p<.05
18
ERI-2: Impact on Outcomes
100%
Months 4-24
Significant Increase in Abstinence
90%
76%
80%
Percentage
70%
Final Interview
68%
60%
RMC
Broke the
Run
76%
RMC
Less Likely to be in
Need of Treatment
68%
57%
Less
Symptoms
49%
50%
OM
46%
37%
40%
27%
30%
19%
20%
10%
0%
of 630 Days
Abstinent
(d=0.29)*
of 7 Subsequent
Quarters in Need
(d= -0.32) *
of 90 Days
Abstinent
(d= 0.23)*
of 11 Sx of
Abuse/Dependence
(d= -0.23)*
Still in need
of Tx
(d= -0.24) *
* p<.05
19
Impact on Primary Pathways to Recovery
(incarceration not shown)
32% Changed
Status in an
Average Quarter
17%
18%
In the
Communityy
Using
(71% stable)
27%
Transition to Tx
- Freq. of Use (0.7)
+ Prob. Orient. (1.4)
+ Desire for Help (1.6)
+ RMC (3.22)
In Recovery
(76% stable)
8%
33%
In Treatment
(35% stable)
Source: ERI experiments (Scott, Dennis, & Foss, 2005)
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)
5%
Again the
Probability of
Entering Recovery
is Higher from
Treatment
20
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
21
We still need to..
• Educate policy makers, staff and clients to have more
realistic expectations
• 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
• Explore changes in funding, licensure and accreditation
to accommodate and encourage above
22
Sources and Related Work
• Dennis, M.L., Foss, M.A., & Scott, C.K (in press). An eight-year perspective on
the relationship between the duration of abstinence and other aspects of recovery.
Evaluation Review.
• Dennis, M. L., Scott, C. K. (in press). Managing addiction as a chronic but
treatable condition. NIDA Addiction Science & Clinical Practice.
• 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.
• 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
23
Treatment, 28, S61-S70.