Transcript Preliminary data from the Persistent Effects of Treatment

Managing Substance Use Disorders
(SUDS) as a Chronic Condition
Michael L. Dennis, Ph.D.
Chestnut Health Systems
720 W. Chestnut,
Bloomington, IL 61701, USA
E-mail: [email protected]
Presentation in the Recovery Conference: Vision to Outcomes
Hartford, CT, May 16-17, 2006
This presentation was supported by funds from the Connecticut Department of Mental Health and Addiction
Services and data from NIDA grant no. R37-DA11323, and R01 DA15523 and SAMHSA/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 [email protected] or 309-820-3805. A copy of
these slides will be posted at www.chestnut.org/li/posters
.
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 focus on
1. Describing the prevalence and characteristics of
this subset of people
2. the course of these disorders, and
3. the results of three experiments designed to
improve the ways in which this condition is
managed across time and multiple episodes of care.
2
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)
3
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%
4
Source: 2002 NSDUH and Dennis & Scott under review
Problems Vary by Age
NSDUH Age Groups
100
90
80
Adolescent
Onset
Remission
Increasing
rate of nonusers
70
Severity Category
No Alcohol or Drug Use
Light Alcohol Use Only
60
Any Infrequent Drug Use
50
40
Regular AOD Use
30
Abuse
20
10
0
Dependence
65+
50-64
35-49
30-34
21-29
18-20
16-17
14-15
12-13
5
Source: 2002 NSDUH and Dennis & Scott under review
Higher Severity is Associated with
Higher Annual Cost to Society Per Person
$4,000
Median (50th percentile)
$3,500
Mean (95% CI)
$3,000
$2,500
$2,000
$1,500
$3,058
This includes people who are in
recovery, elderly, or do not use
because of health problems
$1,613
Higher
Costs
$1,528
$1,309
$1,078
$1,000
$725
$406
$500
$0
$948
$0
$0
No
Alcohol or
Drug Use
Light
Alcohol
Use Only
$231
$231
Any
Infrequent
Drug Use
Regular
AOD
Use
Abuse
Dependence
Source: 2002 NSDUH and Dennis & Scott under review 6
Age of First Use Predicts Symptoms of
Dependence an Average of 22 years Later
100
Under Age 15
% with 1+ Past Year Symptoms
90
Aged 15-17
80
Aged 18 or older
71
70
63
62
60
51
50
40
45
39 37
30
30
48
41
34
23
20
10
0
Tobacco:
Alcohol:
Pop.=151,442,082
Tobacco,
OR=1.3*, Pop.=176,188,916
Alcohol, OR=1.9*,
Pop.=151,442,082
Pop.=176,188,916
OR=1.49*
OR=2.74*
Source:
Marijuana:
Other Drugs:
Pop.=71,704,012
Marijuana, OR=1.5*, Pop.=38,997,916
Other, OR=1.5*,
Pop.=71,704,012 OR=2.65*
Pop.=38,997,916
OR=2.45*
Dennis, Babor, Roebuck & Donaldson (2002) and 1998
* p<.05
NHSDA
7
Study 2. Pathways to Recovery (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.
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
8
Intake Characteristics
• Participants were mostly African-American (88%),
female (59%), and in their 30s (48%); At intake, 32%
were homeless and 25% were involved in the criminal
justice system.
• The most common substances used weekly were:
cocaine (33%), heroin (31%), alcohol (27%), and
marijuana (7%).
• Many met criteria for Major Depression (36%) or
Generalized Anxiety Disorder (36%).
• 54% have been in treatment before (27% 2+ times)
• The participants were initially referred to outpatient
(19%), methadone (19%), intensive outpatient (18%),
halfway house (10%), short term residential (20%),
long term residential (13%).
9
Survival Analysis
• Time frames related to age of use, treatment, and death
were measured across all sources and waves of
information (taking the earliest first use, treatment
episode, and 12 month period of abstinence or death).
• Age at last use was defined as the age when a person
first completed a period of 12 month abstinence or had
died (35 or 2.6% of the people died in 3 years).
• Durations were estimated with Cox Proportional
Hazards Regression
– censoring people who were in treatment or still using,
– censoring years past which we had less than 100 people to
make the estimate, and
– creating a 30 year window of observation on the trajectory of
substance use disorders starting at the time of first use
10
Age Distributions
11
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) 12
100%
90%
21+
80%
15-20*
70%
Percent in Recovery
60%
under 15*
50%
40%
Age of 1st Use Groups
Substance Use Careers are Longer,
the Younger the Age of First Use
30%
20%
10%
0%
* p<.05
(different
from 21+)
0
5
10
15
20
25
Years from first use to 1+ years abstinence
30
Source: Dennis et
al 2005 (n=1,271) 13
100%
90%
0-9*
80%
10-19*
70%
Percent in Recovery
60%
50%
40%
20+
Years to 1st Tx Groups
Substance Use Careers are Shorter
the Sooner People get to Treatment
30%
20%
10%
0%
* p<.05 (different
from 20+)
0
5
10
15
20
25
Years from first use to 1+ years abstinence
30
Source: Dennis et
al 2005 (n=1,271) 14
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) 15
Over 55% Continued to Changed Status Between
Annual Follow-up Interviews (83% over 3 years)
Status at 36 months
100%
90%
80%
In the
community
In Recovery
70%
60%
50%
40%
In Treatment
Incarcerated
30%
20%
In the
community
using
10%
0%
In the Community Using
(57%)
Inc. In Tx.
(6%) (12%)
Recovery
(26%)
Status at 24 months
16
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery
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
17
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)
- number of arrests (1.12)
- ASI legal composite (0.84)
- # of sober friend (0.82)
- per 77 self help sessions (1.41)
Source: Scott et al 2005
18
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.
19
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).
20
Median Length of Stay in Days
The Majority Stay in Tx Less than 90 days
90
60
52
42
33
30
20
0
Outpatient
Intensive
Outpatient
Short Term
Residential
Long Term
Residential
Level of Care
Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment
Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration.
Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .
21
Less Than Half Are Positively Discharged
100%
90%
Other
Discharge Status
80%
70%
Terminated
60%
Dropped out
50%
40%
Completed
30%
20%
Transferred
10%
0%
Outpatient
Intensive Short Term Long Term
Outpatient Residential Residential
Less than 10%
are transferred
Level of Care
Source: Data received through August 4, 2004 from 23 States (CA, CO, GA, HI, IA, IL, KS, MA, MD, ME, MI, MN, MO, MT, NE, NJ, OH, OK, RI, SC, TX,
UT, WY) as reported in Office of Applied Studies (OAS; 2005). Treatment Episode Data Set (TEDS): 2002. Discharges from Substance Abuse Treatment
Services, DASIS Series: S-25, DHHS Publication No. (SMA) 04-3967, Rockville, MD: Substance Abuse and Mental Health Services Administration.
Retrieved from http://wwwdasis.samhsa.gov/teds02/2002_teds_rpt_d.pdf .
22
Adolescent and Adult Treatment Program
GAIN Clinical Collaborators
Number of
GAIN Sites
30 to 60
10 to 29
2 to 9
1
One or more state or county wide systems uses the GAIN
One or more state or county wide systems considering using the GAIN
07/05
23
100%
80%
60%
40%
20%
0%
100%
80%
60%
40%
20%
0%
Multiple Co-occurring Problems
Contribute to Chronicity
Health Distress
Internal Disorders
External Disorders
Crime/Violence
Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Other (n=2617)
Exception
Adults
Dependent (n=1221)
Other (n=385)
Source: GAIN Coordinating Center Data Set
24
Percent in Past Month Recovery*
Treatment Outcomes by Level of Care:
Recovery*
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)
25
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
26
Source: Godley et al 2002, in press
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)
27
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
ACC Enhancements
•
•
•
•
Continue to participate in UCC
Home Visits
Sessions for adolescent, parents, and together
Sessions based on ACRA 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)
28
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.
29
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, forthcoming
UCC
ACC
* p<.05
30
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, forthcoming
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Marijuana (OR=1.98*)
* p<.05
31
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, forthcoming
Marijuana (OR=11.15*)
* p<.05
32
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 ACC preliminary findings are published and the main
findings are currently under review.
• Several CSAT grantees are also seeking to replicate ACC as part
of the Adolescent Residential Treatment (ART) and Assertive
Adolescent Family Therapy (AAFT) programs.
• A second ACC experiment is currently under way to evaluate
whether providing contingency management will further
improve outcomes.
• The ACC manual is being distributed via the website and the
CD you have been provided.
33
The Early Re-Intervention (ERI) Experiments
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 (9597% per wave)
Quarterly for 4 years (95 to
97% per wave)
Data Sources GAIN, CEST, Urine, Salvia
Staff logs
GAIN, CEST, CAI, Neo,
CRI, Urine, Staff logs
Publication
Scott & Dennis, under review
(12 month findings)
Dennis, Scott & Funk 2003;
Scott, Dennis & Foss, 2005
Funding Source NIDA grant R37-DA11323
34
100%
80%
60%
40%
20%
0%
Sample Characteristics of ERI 1 & 2 Experiments
African American
Age 30-49
Female
Employed
Dependence
Prior Treatment
Residential Treatment
Other Mental Disorders
Homeless
ERI 1 (n=448)
Physical Health Problems
ERI 2 (n=446)
35
Need For Treatment Re-Intervention
•
Eligibility: Not already in treatment or incarcerated and
living in the community
•
Need: Yes to at least one of the following…
(a) During the past 90 days, have you used alcohol,
marijuana, cocaine, or other drugs on 13 or more days?
(b) During the past 90 days, have you gotten drunk or been
high for most of 1 or more days?
(c) During the past 90 days, has your alcohol or drug use
caused you not to meet your responsibilities at
work/school/home on 1 or more days?
(d) During the past week, had withdrawal symptoms when you
tried to stop, cut down, or control your use?
(e) Do you feel that you need to return to treatment?
(f) During the past month, has your substance use caused you
any problems?
36
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
37
H1: RMC Clients will return to treatment sooner
1.0
Median of 376 vs.
600 days,
Wald=5.2, p<.05
.9
Percent to be Readmitted
.8
.7
.6
.5
Control
(51% readmitted)
.4
RMC
(64% readmitted)
.3
OR: 1.34
X2(1)=6.8, p<.01
.2
.1
0.0
0
90
180
270
360
450
Days to Readmission
540
630
720
38
H2: RMC clients will receive more treatment
70
60
% with 90+ Days
30%
62
25%
50
50
25%
20%
17%
40
15%
30
10%
20
10
5%
0
0%
Control
RMC
t(390)=2.65, p<.05
Control
% with 90+ days of Subsequent
Treatment (months 4-24)
Mean Days of Subsequent Treatment
(months 4-24)
Days
RMC
OR 1.61, X2(1)=4.1, p<.05
39
H3: RMC clients will be less likely to use at 24m
100%
90%
80%
70%
56%
60%
50%
43%
40%
30%
20%
10%
0%
Control (n=244)
X2(1) = 7.7, p<.01
RMC (n=224)
40
However, 32% of individuals change status between the
beginning and end of the quarter (82% over two years)
Status at the end of Quarter
End of
Quarter
100%
90%
80%
In the
community
In Recovery
70%
60%
50%
40%
In Treatment
30%
20%
Incarcerated
In the
community
using
10%
0%
In the Community Using
(41%)
Inc.
(5%)
In Tx.
(12%)
Recovery
(42%)
(3,136 quarterly
transition 41
Status at beginning
of Quarter
Beginning of Quarter
Observations on 448 unique people)
Impact on Primary Pathways to Recovery
(incarceration not shown)
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
42
Other Variables That Lost
Significance in Multivariate Model
• Problem Recognition, External Pressure, Internal
Motivation, Treatment Resistance
• Current Withdrawal, Number of Diagnosis,
Emotional Problems, Illegal Activity,
Homelessness
• Coming from a controlled environment
• Involvement with the Criminal Justice System,
Mental Health, Health, or Training/School
Systems
• Lifetime number of prior treatment, arrests
• Gender, Race, Age, Employment
43
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
44
Adherence to Recovery Management Checkup
(RMC) Protocol in ERI 1 vs. 2
Generally averaged as well
or better
100%
80%
Improved
60%Screening
40%
Improved
Retention
20%
Avg
Min
Stayed in Tx
14+ days
(60% avg)
Showed to Tx
(35% avg)
Showed to Tx
Assessment
(42% avg)
Agreed to Tx
Assessment
(48% avg)
Attended Linkage
(99% avg)
ERI 1Max ERI 2
Needed Tx
(45% avg)
Follow-up
(96% avg)
0%
Quality assurance and transportation
assistance reduced the variance
45
Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis, forthcoming)
Relative to Control clients, RMC clients
were more likely to return to treatment
% Readmitted (Months 4-12)
100%
100%
90%
90%
80%
80%
70%
70%
60%
60%
50%
50%
40%
38%
36%
30%
30%
40%
30%
22%
20%
20%
10%
10%
0%
0%
ERI 1 (d=+.17)T
ERI 1 Control
ERI 1 RMC
ERI-2 (d=+.30)*
ERI 2 Control
ERI 2 RMC
*p<.05
46
Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scot & Dennis, forthcoming
RMC clients received more
Total Days of Treatment
50
Mean Days of Treatment Received (months 4-12)
40
50
40
30
28
30
30
20
20
17
20
10
10
0
0
ERI 1 (d=+.16)
ERI 11 Control
OM
ERI
ERI
ERI1 1RMC
RMC
ERI-2 (d=+.28)*
ERI 2 ERI
OM 2 Control
ERI 2 RMC
ERI 2 RMC*p<.05
47
Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)
RMC clients were less likely to have
Successive Quarters in Need of Treatment
% with any successive quarters in need of treatment
100%
100%
90%
90%
80%
80%
70%
60%
50%
70%
63%
54%
42%
60%
50%
42%
40%
40%
30%
30%
20%
20%
10%
10%
0%
0%
ERI 1 (d= -.00)
ERI1 1Control
OM
ERI
ERI
ERI11RMC
RMC
ERI-2 (d= -.23)*
ERI 2 ERI
OM 2 Control
ERI 2 RMC
ERI 2 RMC*p<.05
48
Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)
RMC clients were less likely to be
in need of treatment at the end of 12 months
In Need of Tx (using in community) at 12 months
100%
90%
80%
Every Quarter this difference has been
growing; Hence our plans to go out 4 years
70%
60%
50%
50%
90%
80%
70%
60%
52%
100%
60%
47%
50%
40%
40%
30%
30%
20%
20%
10%
10%
0%
0%
ERI 1 (d= -.07)
ERI
1 1Control
ERI
OM
ERI 1
1 RMC
RMC
ERI
ERI-2 (d= -.32)*
ERI 2 RMC *p<.05
ERI 2ERI
OM2 Control
ERI 2 RMC
49
Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)
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 engagement for at least 14 days
upon readmission helped to improve outcomes
50
Other Emerging Recovery Support Initiatives
• Interactive phone and web based monitoring and
recovery support
• Self help groups
• Recovery homes
• Recovery High Schools & Colleges
• Well-briety movement in Indian Country
• Recovery advocacy movement
• Network for the Improvement of Addiction Treatment
(NIATx; http://www.pathstorecovery.org/
• Washington Circle Group
(http://www.washingtoncircle.org/) and other efforts to
introduce performance monitoring
51
Reprise
• These studies provide converging evidence
demonstrating that substance use disorders commonly
present with a wide range of co-occurring problems
that are likely to interfere with recovery.
• They show that 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 make it to recovery
• The three experiments demonstrated that it is feasible
to alter the substance use trajectories and treatment
careers.
52
We 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
53
Sources and Related Work
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•
•
•
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•
•
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•
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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.
GAIN Coordinating Center Data Set (2005). Bloomington, IL: Chestnut Health Systems. See 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 cooccurring 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. (under review). Managing substance use disorders (SUD) as a chronic condition. NIDA Science
and Perspectives.
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.
Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R., & Passetti, L. (2002). Preliminary outcomes from the assertive
continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment,
23, 21-32.
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)
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.
54