Transcript Shifting the Paradigm

Shifting the Treatment Paradigm
to Managing Addiction as a
Chronic Condition
Michael Dennis, Ph.D.
Chestnut Health Systems,
Bloomington, IL
Presentation at the Haymarket Center's 15th Annual Summer Institute On Addictions, Oakbrook Terrace, IL, June 9-11, 2009..
This presentation was supported by funds from NIDA grants no. R13 DA027269, 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
[email protected] or 309-820-3805.
Goals of this Presentation are to
1. Identify some of the problems with acute care
model of treatment
2. Describe the characteristics of chronic care
models of treatment
3. Develop strategies for making treatment more
consistent with a chronic care model
2
Agenda

Virtual walk through clinical practice as usual

A fearless appraisal of the strengths and weakness
of the current systems

A review of what we mean by saying substance
use disorders are chronic

Characteristics of Chronic Care models

How we can improve practice in our own
programs
3
Virtual walk through clinical practice

Call Appointment
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
Person or voicemail?
Time on hold?
What information collected? Is it Used?
Appointment scheduled right away or after how long?
Time from first contact to appointment?
Limited or Flexible of appointment time?
Implications for work, child care, transportation?
Any common complements or complaints?
Facility
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Transportation, parking, signage issues?
Institution vs. warm feel, comfort, privacy?
Self contained vs. having to move around?
Any common complements or complaints?
4
Continued

Intake
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Waiting room comfort, beverage, entertainment, time?
Arrangements for family or friends?
Exams, urine tests, other invasive procedures?
Any information from initial call used/trusted?
Open, rating or standardized assessment?
Objectivity, Consistency and formal rules for diagnosis,
placement and treatment planning?
Speed of interpretation & recommendations?
Time to first treatment?
Any intervening services or assistance?
Time and linkage to first treatment plan?
What are the most common recommendations?
Any common complements or complaints?
5
Continued

Treatment
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Scheduling flexibility
Privacy, comfort,
Once assigned is intake assessment used / trusted or are
some or all of the assessment repeated in early treatment?
How well are the actual treatment plan and services linked
to assessment?
Is their an orientation or motivational interviewing track
everyone goes through in the beginning?
Are there special tracks or phases?
What happens if someone does not show for treatment the
first time? Once? More than once?
What happens if someone does not appear to be getting
along with their primary counselor?
What happens if someone continues to use?
Any common complements or complaints?
6
Continued

Continuing care
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How long does treatment usually last for the middle 50%?
How often are people recommended to transfer to another
level of care or program? How often do they get there?
How are clients referred to other services?
How is it monitored whether they get them?
Are these referrals passive or assertive?
What happens if they do not show to the other level of
care, program or service?
Are there do not readmit lists, why are clients on them and
how often does this happen?
How often would you have a least one follow-up with
someone 90 or more days after the initial treatment
discharge?
Any common complements or complaints?
7
Continued

What would change if….
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
The person calling in had been in treatment 5 or more
times before?
Had been in your program 5 or more times?
Had been in your program 5 or more times in the last 12
months?
Do you..
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Monitor whether the services recommended are actually
delivered to a manual or clear quality standard beyond
simple length of stay or paper work?
Know the most common presenting needs of your clients
and have evidenced based approaches to deal with them?
Have formal training protocols for staff on assessment,
treatment and other services you routinely provide?
Know the profile of clients that you do well with, do ok
with, do badly with?
8
Common Complaints

Cold inadequate facilities and lack of privacy

Poor staff engagement (vs. customer service)

Burdensome procedures and process (e.g., having to wait,
answering the same questions to different people, answering
questions that did not seem linked to services received,
information not being used)

Failure to appreciate the complexity and interaction of
multiple problems and their implications for what is
needed/feasible

Arbitrary decisions and consequences

Lack of options and administrative discharge of people for
confirming their diagnosis
9
Key Problem 1:
Current Treatment System is Insufficient

Less than 1 in 10 people with abuse/dependence getting to
treatment

Less than 50% stay 50 days (~7 weeks)

Less the 25% stay the 3 months recommended by NIDA
researchers

Less than half have positive discharges

After intensive treatment, less than 10% step down to
outpatient care
10
Key Problem 2:
Lack of Standardized Assessment for…

Substance use disorders (e.g., abuse, dependence,
withdrawal), readiness for change, relapse potential and
recovery environment

Common mental health disorders (e.g., conduct, attention
deficit-hyperactivity, depression, anxiety, trauma, selfmutilation and suicidality)

Crime and violence (e.g., inter-personal violence, drug related
crime, property crime, violent crime)

HIV risk behaviors (needle use, sexual risk, victimization)

Child maltreatment (physical, sexual, emotional)
11
Key Problem 3:
No or Inconsistent Use of Placement Criteria

In practice, programs primarily refer people to the limited
range of services they have readily available.

Knowing nothing about the person other than what door they
walked through we can correctly predict 75% (kappa=.51) of
the adolescent level of care placements.

The American Society for Addiction Medicine (ASAM) has
tried to recommend placement rules for deciding what level of
care an adolescent should receive based on expert opinion, but
run into many problems.
12
Key Problem 3 (continued):
Examples of problems with placement

difficulty synthesizing multiple pieces of information

inconsistencies between competing rules

the lack of the full continuum of care to refer people to

having to negotiate with the participant, families and funders
over what they will do or pay for

there is virtually no actual data on the expected outcomes by
level of care to inform decision making related to placement
13
Key Problem 4:
Need for Specific Protocols and Services Related to

Motivational Interviewing and other protocols to help them
understand how their problems are related to their substance
use and that they are solvable

Need for residential, IOP and other types of structured
environments to reduce short term risk of relapse

Relapse Prevention

Proactive urine monitoring

Need for recovery coaches, recovery schools, recovery housing
and other adolescent oriented self help groups / services

Detoxification services and medication

Tobacco cessation
14
Key Problem 4 (continued):
Need for Specific Protocols and Services Related to

Need for specific protocols related to trauma, suicide ideation,
and para-suicidal behavior

Need for victimization or child maltreatment interventions
(not just reporting protocols)

HIV Intervention to reduce high risk pattern of sexual
behavior

Anger Management

Psychiatric services related to depression, anxiety, ADHD,
conduct disorder, and ASPD/BPD

Work or School problems

Family problems
15
Key Problem 5:
Need for Tracks, Phases and Continuing Care

Over half of adults and a third of adolescents are “returning”
to treatment (more than a quarter for the second or more time)

We need to understand what did and did not work the last time
and have alternative approaches

We need tracks or phases that recognize that they may need
something different or be frustrated by repeating the same
material again and again

We need to have better step down and continuing care
protocols

We need better protocols for linking people to on-going
recovery support services
16
Current Paradigm of “Acute Care”
Treatment and Research

Focus on initial assessment and placement

Brief and/or short term single episodes of care focused
primarily on substance use, motivation, cognition and coping
skills

Indirect focus on changing the social recovery environment
(with TCs being a major exception)

Minimal or no post-discharge check-ups

Evaluation of outcomes over relatively short periods of time
(6-12 months) with the expectation that improvements should
continue after treatment (i.e., an “acute care” model)
17
The Rise of Chronic Conditions
From 1900 to 1999…

Medical advances in treating accidents and infectious diseases
reduced their likelihood of being the cause of death from over
60% to under 20%.

This led to a rise in chronic conditions (e.g., heart disease,
diabetes, cancer, respiratory illnesses, Alzheimer's) being the
cause of death from under 20% to over 70%.

It is estimated that modifiable behaviors caused or exacerbated
48% or more of these chronic conditions

This includes 22% who used tobacco, alcohol and other drugs
and another 4% who engaged in behaviors that can be substance
related (e.g., sexual transmission, motor vehicle, fire arm)
Source: Mokdad et al 2004.
18
What do we mean by saying something is a
chronic condition?

There are often multiple interacting biological, behavioral and
environment factors associated with current and future severity

The condition lasts over many years

There is a large risk of relapse after treatment or initial periods
of remission

Multiple episodes of care are often required

While treatment is typically more effective than no treatment,
each episode is associated with a worse prognosis

There are some who may require continuous treatment or
support for the rest of their lives
19
Need for a Chronic Care Model for
Managing Addiction

Many consumers and clinicians view substance use as a
chronic relapsing condition.

An emerging body of evidence from treatment epidemiology
suggests that the typical pathway to recovery currently
involves multiple episodes of care over many years.

Among people admitted to publicly funded treatment
reported in TEDS, for instance, 60% of the people had been
been in treatment before (including 23% 1x, 13% 2xs, 7%
3xs, 17% 4 or more).

There is a high risk of relapse after treatment and the
prognosis gets worse with each readmission
20
Brain Activity on PET Scan After Using Cocaine
With repeated use,
there is a cumulative
effect of reduced
brain activity which
requires increasingly
more stimulation (i.e.,
tolerance)
Normal
Cocaine Abuser (10 days)
Even after 100 days
of abstinence
activity is still low
Cocaine Abuser (100 days)
Photo courtesy of Nora Volkow, Ph.D. 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.
21
Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine
22
Other Aspects of Recovery
by Duration of Abstinence of 8 Years
100%
% of Clean and
Sober Friends
90%
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)
Source: Dennis, Foss & Scott (2007)
% Days of Illegal
Activity (of 30 days)
23
Sustained Abstinence Also Reduces
The Risk of Death
The Risk of Death
goes down with
years of sustained
abstinence
Users/Early
Abstainers
more likely
to die in
the next 12
months
It takes 4 or
more years of
abstinence for
risk to get
down to
community
levels
(Matched on Gender,
Race & Age)
Source: Scott, Dennis, Simeone & Funk (forthcoming)
24
Characteristics of Chronic Care
Models of Treatment

Customer service and structured/firm but non confrontational

Assertive outreach, engagement, continuing care, and follow-up

Placement into tracks, phases or services that take into account
prior services and the past response to treatment

Increased focus on multiple problems, services and systems

Increased focus on monitoring adherence and adjusting
intervention

Use of checkups and early re-intervention

Consistent assessment and records over multiple episodes of
care
25
Meta analyses and Implementation
Science Suggest that Major
Predictors of Bigger Effects are:
1.
Used triage to focus on the highest severity
subgroup and/or an explicit target group
2.
Chose a strong intervention protocol based on
prior evidence
3.
Used quality assurance to ensure protocol
adherence and project implementation
4.
Used proactive case supervision of individual
26
Impact of the numbers of Favorable
features on Recidivism (509 JJ studies)
Average
Practice
Source: Adapted from Lipsey, 1997, 2005
27
Crime/Violence and Substance Problems
Interact to Predict Recidivism
Crime/
Violence
predicted
recidivism
80%
60%
40%
20%
Crime and
Violence
Scale
0%
Knowing both was the
best predictor
Source: CYT & ATM Data
12 month recidivism
100%
Substance
Problem
Scale
Substance Problem
Severity predicted
recidivism
28
100%
80%
Crime/
Violence
predicted
violent
recidivism
60%
40%
20%
Crime and
Violence
Scale
0%
Knowing both was the
best predictor
Source: CYT & ATM Data
12 month recidivism
To violent crime or arrest
Crime/Violence and Substance Problems
Interact to Predict Violent Crime or Arrest
Substance
Problem
Scale
(Intake) Substance
Problem Severity did
not predict violent
recidivism
29
Cognitive Behavioral Therapy (CBT) Interventions
that Typically do Better than Usual Practice in
Reducing Recidivism (29% vs. 40%)











Aggression Replacement Training
Reasoning & Rehabilitation
Moral Reconation Therapy
Thinking for a Change
Interpersonal Social Problem Solving
MET/CBT combinations and Other manualized CBT
Multisystemic Therapy (MST)
Functional Family Therapy (FFT)
Multidimensional Family Therapy (MDFT)
Adolescent Community Reinforcement Approach (ACRA)
Assertive Continuing Care
NOTE: There is generally little or no differences in mean
effect size between these brand names
Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004
30
Implementation is Essential
(Reduction in Recidivism from .50 Control Group Rate)
The best is to
have a strong
program
implemented
well
Thus one should optimally pick the
strongest intervention that one can
implement well
Source: Adapted from Lipsey, 1997, 2005
The effect of a well
implemented weak program is
as big as a strong program
implemented poorly
31
Number of Clinical Problems by Level of Care
100%
The Severity of
People is NOT
the same across
levels of care.
90%
80%
70%
60%
50%
40%
67%
30%
50%
20%
78%
0 to 1
55%
2 to 4
39%
10%
5 or more
0%
OP
IOP
LTR
Source: CSAT 2007 AT Outcome Data Set (n=12,824)
MTR
STR
32
No. of Problems* by Severity of Victimization
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None
One
Two
Three
Four
Five+
Low
(OR 1.0)
Mod.
(OR=4.8)
High
(OR=13.8)
Severity of Victimization
* (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)
Those with
high lifetime
levels of
victimization
have 117 times
higher odds of
having 5+
major
problems*
33
Percent in Past Month Recovery*
Recovery* by Level of Care:
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
CC
better
OP &
Resid
Similar
Pre-Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
* Recovery defined as no past month use, abuse, or dependence symptoms while living in
the community. Percentages in parentheses are the treatment outcome (intake to 12 month
change) and the stability of the outcomes (3months to 12 month change)
Source: CSAT Adolescent Treatment Outcome Data Set (n-9,276)
34
Findings from the
Assertive Continuing Care (ACC)
Experiment

183 adolescents admitted to residential
substance abuse treatment

Treated for 30-90 days inpatient, then
discharged to outpatient treatment

Random assignment to usual continuing care
(UCC) or “assertive continuing care” (ACC)

Over 90% follow-up 3, 6, & 9 months post
discharge
Source: Godley et al 2002, 2007
Time to Enter Continuing Care and Relapse
after Residential Treatment (Age 12-17)
100%
Percent of Clients
90%
80%
70%
Relapse
60%
50%
Cont.
Care
Admis.
40%
30%
20%
10%
0%
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
36
ACC Enhancements

Continue to participate in UCC

Home Visits

Sessions for adolescent, parents, and together

Sessions based on Adolescent Community
Reinforcement Approach (A-CRA) 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)
37
Assertive Continuing Care (ACC)
Hypotheses
Assertive
Continuin
g Care
General
Continuin
g Care
Adherence
Early
Abstinence
Sustained
Abstinence
Relative to UCC, ACC will increase General
Continuing Care Adherence (GCCA)
GCCA (whether due to UCC or ACC) will be
associated with higher rates of early abstinence
Early abstinence will be associated with higher
rates of long term abstinence.
38
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
ACC Improved Adherence
Weekly Tx
Weekly 12 step meetings
Relapse prevention*
Communication skills training*
Problem solving component*
Regular urine tests
Meet with parents 1-2x month*
Weekly telephone contact*
Contact w/probation/school
Referrals to other services*
Follow up on referrals*
Discuss probation/school compliance*
Adherence: Meets 7/12 criteria*
Source: Godley et al 2002, 2007
UCC
ACC
* p<.05
39
GCCA Improved Early (0-3 mon.) Abstinence
100%
90%
80%
70%
60%
55%
50%
43%
36%
40%
30%
55%
38%
24%
20%
10%
0%
Any AOD (OR=2.16*)
Low (0-6/12) GCCA
Source: Godley et al 2002, 2007
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Marijuana (OR=1.98*)
* p<.05
40
Early (0-3 mon.) Abstinence Improved
Sustained (4-9 mon.) Abstinence
100%
90%
80%
73%
69%
70%
59%
60%
50%
40%
30%
20%
19%
22%
22%
10%
0%
Any AOD (OR=11.16*)
Alcohol (OR=5.47*)
Early(0-3 mon.) Relapse
Early (0-3 mon.) Abstainer
Source: Godley et al 2002, 2007
Marijuana (OR=11.15*)
* p<.05
41
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 ACC1 main findings are published and findings from
two subsequent experiments are currently under review

CSAT is currently replicating ACRA/ACC in 32 sites

The ACC manual is being distributed via the website and
the CD.
42
To further improve the effectiveness
of substance abuse treatment, we
need to:




identify and address the complex array of co-occurring
problems that can impede sustained recovery,
move beyond a system of passive referrals for cooccurring problems to an integrated and assertive system
of care,
proactively monitor patients after the traditional points of
discharge, help them with long term recovery
management, and promote early re-intervention when
appropriate, and
generally shift the paradigm of clinical models from an
acute care approach to models that effectively manage
chronic substance use disorders.
43
Policy and Research Implications

Change systems of care and financial support mechanisms
from acute to chronic care models.

Identify the complex clusters of co-occurring problems –
both in terms of statistical factors and population
subgroups.

Develop effective recovery management strategies.

Examine treatment effects across episodes of care.

Examine the predictors of the trajectories for achieving
and sustaining recovery over longer periods of time.

Conduct more longitudinal research over the lifespan of
the substance use and treatment careers.
44