Managing Substance Use Disorders (SUDS) as a Chronic Condition

1. Managing Substance Use Disorders (SUDS) as a Chronic Condition Michael L. Dennis, Ph.D. & Christy K Scott, Ph.D. Chestnut Health Systems 720 W. Chestnut, Bloomington, IL 61701, USA E-mail: mdennis@chestnut.org Presentation in the 4th Plenary Session: Life Cycle’s Impact on Service Delivery and on Policies at the 48th International Council on Alcohol and Addictions Budapest, Hungary, 23 October 2005 This presentation was supported by funds and data from NIDA grant no. R37-DA11323 and 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 mdennis@chestnut.org or 309-820-3805. A copy of these slides will be posted at www.chestnut.org/li/posters .

2. 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 • Describing the prevalence and characteristics of this subset of people • the course of these disorders, and • the results of two experiments designed to improve the ways in which this condition is managed across time and multiple episodes of care.

3. 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)

4. Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246) Dependence 5% Abuse 4% No Alcohol or Regular AOD Drug Use 32% Use 8% Any Infrequent Drug Use 4% Light Alcohol Use Only 47% Source: 2002 NSDUH and Dennis et al forthcoming

5. Adolescent Onset Remission Problems Vary by Age NSDUH Age Groups Increasing rate of non-users 100 Severity Category 90 No Alcohol or Drug Use 80 70 Light Alcohol Use Only 60 Any Infrequent Drug Use 50 40 Regular AOD Use 30 Abuse 20 10 Dependence 0 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Source: 2002 NSDUH and Dennis et al forthcoming

6. Mean (95% CI) $3,058 This includes people who are in recovery, elderly, or do not use because of health problems Higher Costs $1,613 $1,528 $1,309 $1,078 $948 Higher Severity is Associated with Higher Annual Cost to Society Per Person $4,000 Median (50th percentile) $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $725 $406 $500 $231 $231 $0 $0 $0 No Alcohol or Light Alcohol Regular AOD Any Dependence Abuse Infrequent Drug Use Use Only Drug Use Use Source: 2002 NSDUH and Dennis et al forthcoming

7. 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).

8. Multiple Co-occurring Problems Contribute to Chronicity 100% 100% 40% 60% 80% 20% 20% 40% 60% 80% 0% 0% Health Distress Internal Disorders External Disorders Crime/Violence Criminal Justice System Involvement Adults Adolescents Exception Dependent (n=1221) Dependent (n=3135) Other (n=385) Other (n=2617) Source: GAIN Coordinating Center Data Set

9. Substance Use Careers Last for Decades 100% 90% 80% Percent in Recovery 70% Median duration of 27 years (IQR: 18 to 30+) Years from first use to 1+ years abstinence 60% 50% 40% 30% 20% 10% 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

10. 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% Years from first use to 1+ years abstinence 60% under 15* 50% 40% 30% 20% * p<.05 (different from 21+) 10% 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

11. Substance Use Careers are Shorter the Sooner People get to Treatment 100% 0-9* 90% 80% 10-19* Years to 1st Tx Groups Percent in Recovery 70% Years from first use to 1+ years abstinence 60% 50% 40% 20+ 30% 20% 10% * p<.05 (different from 20+) 0% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

12. 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% 20% 10% 0% 0 5 10 15 20 25 Source: Dennis et al 2005 (n=1,271)

13. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery P not the same in both directions 6% 7% 25% 30% 8% 13% 29% 4% 7% 44% 31% 28% Treatment is the most likely path to recovery Incarcerated (37% stable) In the In Recovery Communit y (58% stable) Using (53% stable) In Treatment (21% stable) Source: Scott et al 2005

14. 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 13% In Recovery Communit y (58% stable) Using 29% (53% stable) 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

15. The Early Re-Intervention (ERI) Experiments Funding Source NIDA grant R37-DA11323

16. Sample Characteristics of ERI 1 & 2 Experiments 100% 20% 40% 60% 80% 0% African American Age 30-49 Female Employed Dependence Prior Treatment Residential Treatment Other Mental Disorders Homeless ERI 1 (n=448) ERI 2 (n=446) Physical Health Problems

17. 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

18. 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

19. Generally averaged as well or better ImprovedScreening Improved Retention ERI 2 Quality assurance and transportation assistance reduced the variance Adherence to Recovery Management Checkup (RMC) Protocol in ERI 1 vs. 2 100% 80% 60% 40% 20% 0% (96% avg) Follow-up Needed Tx (45% avg) Agreed to Tx (48% avg) Assessment (60% avg) 14+ days Stayed in Tx (42% avg) (35% avg) Showed to Tx Assessment Showed to Tx (99% avg) Attended Linkage ERI 1 Max Avg Min Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis, forthcoming)

20. ERI 1 Control ERI 1 RMC ERI 2 Control ERI 2 RMC 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% 38% 36% 40% 40% 30% 30% 30% 22% 20% 20% 10% 10% 0% 0% ERI 1 (d=+.17)T ERI-2 (d=+.30)* *p<.05 Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scot & Dennis, forthcoming

21. ERI 1 Control ERI 1 RMC ERI 2 Control ERI 2 RMC RMC clients received more Total Days of Treatment Mean Days of Treatment Received (months 4-12) Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)

22. ERI 1 Control ERI 1 RMC ERI 2 Control ERI 2 RMC RMC clients were less likely to have Successive Quarters in Need of Treatment % with any successive quarters in need of treatment Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)

23. ERI 1 Control ERI 1 RMC ERI 2 Control ERI 2 RMC 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 Every Quarter this difference has been growing; Hence our plans to go out 4 years Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)

24. Again the Probability of Entering Recovery is Higher from Treatment Impact on Primary Pathways to Recovery (incarceration not shown) • 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) 17% 18% In the Community y In Recovery Using (76% stable) (71% stable) 27% 8% 33% 5% • Transition to Tx • Freq. of Use (0.7) • + Prob. Orient. (1.4) • + Desire for Help (1.6) • + RMC (3.22) In Treatment (35% stable) Source: ERI experiments (Scott, Dennis, & Foss, 2005)

25. Reprise • There is clearly a subset of people for whom substance use disorder are a chronic condition that last for many years, is expensive, and confounded with a wide range of other problems. • Shifting to a recovery management paradigm requires a better understanding of how people cycle through relapse, incarceration, treatment and recovery • While the natural cycle may take almost a decade and 3 to 4 episodes of care – it can be experimentally altered with more proactive early intervention protocols.

26. Implications • We need to 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 • Need for changes in funding, licensure and accreditation to accommodate and encourage above

27. Sources and Related Work • 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 co-occurring 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., 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. • 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.