A System of Care for Substance Use as a Chronic Health Problem

1. A System of Care for Substance Use as a Chronic Health Problem Rachel Gonzales Ph.D, Professor Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine University of California at Los Angeles www.uclaisap.org rachelmg@ucla.edu Supported by: National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) California Alcohol and Drug Programs (ADP)

2. Understanding addiction as a chronic health problem

3. Addiction Paradigms Demonization Criminalization Psychiatric views Socialization Medicalization Sinful/Immoral Criminal/Illegal Mental Disorder- DSM Learned Behavior/Habit Acute (Brain) Disease Neuro-Science & Longitudinal Research Chronic Illness Leshner, 2001; Anglin et al., 1997

4. Neuroscience SupportsAddiction = Chronic Health Problem …with biological, psychological and behavioral components

5. Interact with neurochemistry (reward pathway of the Brain) Results: - Feel Good – Euphoria/reward - Feel Better – Reduce negative feelings Like Natural Rewards: Food, Sex Biological ResponseHow Do Drugs Work?

6. Pathway for Understanding Addictive Effectsof Drugs on the Brain Reward Pathway

7. FOOD SEX 200 200 NAc shell 150 150 DA Concentration (% Baseline) 100 100 15 % of Basal DA Output 10 Empty Copulation Frequency 50 Box Feeding 5 0 0 Scr Scr Scr Scr 0 60 120 180 Bas Female 1 Present Female 2 Present Mounts Time (min) Sample Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Intromissions Ejaculations Source: Di Chiara et al. Source: Fiorino and Phillips Natural Rewards Elevate Dopamine in the Brain

8. COCAINE AMPHETAMINE Accumbens 1100 Accumbens 400 1000 900 DA 800 DA 300 DOPAC 700 DOPAC % of Basal Release HVA HVA 600 % of Basal Release 500 200 400 300 100 200 100 0 0 0 1 2 3 4 5 hr Time After Amphetamine Time After Cocaine MORPHINE NICOTINE 250 Accumbens 250 Dose (mg/kg) 200 Accumbens 0.5 200 Caudate 1.0 2.5 % of Basal Release 150 % of Basal Release 10 150 100 0 1 2 3 hr 100 0 1 2 3 4 5 hr 0 0 0 1 2 3 4 5hr Time After Nicotine Time After Morphine Drugs Also Bring Reward (via Dopamine)

9. What have we learned through Positron Emission Tomography (PET)?

11. Addiction leads to…. Prolonged Changes In the Brain in Lasting Ways “Cocaine Addict” Brain “Healthy” Brain

12. BRAIN CHANGESappear prominently in PET scans of current and past drug users Drug users have far less dopamine activity (right), as is indicated by the depletion (dark red shows disruption), compared to the controls (left)Studies show that this difference contributes todependence and a diseased brain

13. Behavioral ResponseHow Drugs Work • Loss of control • Continued compulsive use despite harmful consequences • Multiple relapses preceding stable recovery

14. Why is Continued Treatment Critical? Normal Control Meth user (36 months abstinent) Meth user (1 month abstinent) Partial Recovery of Dopamine Transporters After Prolonged Abstinence

15. Longitudinal Research Support for Addiction as a Chronic Illness

16. Advancing the notion of Drug Careers and Treatment Careers…. • Landmark study: UCLA ISAP researchers (Hser, Anglin et al) followed up a cohort of 581 male heroin addicts admitted to the California Civil Addict Program (1962-64) for over 30 years. • The program was the only major publicly-funded drug treatment program available in California in the 60s. • Tx: combo of inpatient and outpatient drug treatment to narcotic-dependent criminal offenders committed under court order.

17. Status of Sample at 3 Interview Points

18. 22% 2% 6% 7% 4% Methadone Maintenance 48% 12% Natural History of Narcotic Addiction Among Sample(N=581)

19. Causes of Death Among Sample (N = 271) a b c d e aIncludes overdose, poisoning, drug dependence, and suicide by drugsbIncludes motor vehicle, suicide, firearms, homicide, and fallscIncludes alcoholic cirrhosis, alcohol dependence, and poisoning by alcoholdIncludes kidney disease, diabetes, GI, and epilepsy seizureseIncludes viral hepatitis, AIDS, TB, and staphylococol depticemia

20. Implications for the Field • Cannot ignore the chronic nature of addiction and the associated long-term effects of heroin addiction in terms of morbidity, mortality, criminal justice involvement, and overall level of functioning • Compared to a US Population sample, heroin addiction reduces life expectancy by an average of 18 years

21. Other Long-term Outcome Studies • Alcohol: Vaillant et al. conducted multiple long-term follow-up studies with alcoholics (post-tx). Findings repeatedly show that alcoholics experience multiple relapses and re-treatments with only 30-50% achieving stable abstinence. • Cocaine: Hser et al. 10-yr follow-up study of cocaine users post-tx found that fewer than 50% achieve extended periods of abstinence AND most re-enter treatment multiple times. • Methamphetamine: Marinelli-Casey et al. 3-year follow up study (600 MA users post-tx) found that 50% continue to use MA at a moderate or severe level throughout the 36 month period.

22. Re-Addiction Following Prison Treatment Research Institute • Vaillant • 447 opiate addicts 91% • Maddux & Desmond • 594 opiate addicts 98% • Nurco & Hanlon • 355 opiate addicts 88% • Hanlon & Nurco • 237 mixed addicts 70% • Other Studies: Simpson, Wexler, Inciardi, Hubbard, Anglin

23. Developing a Treatment System that is Responsive

24. Given the Research, there has been a Paradigm Shift in Treatment Response… Focus has increasingly shifted from an acute, model of tx towards a chronic care model

25. Shift is been important for adequately understanding and managing substance use disorders and the recovery process Are we there Yet?

26. Public Expectations of Substance Abuse Interventions • Safe, complete detoxification • “The 28 day cure” • Put them in a box, something happens and they come out fixed • The washing machine model: Put a “dirty addict” in, run the washer, and take out a “clean citizen” • Results in: • Reduced use of medical services • Eliminate crime • Return to employment • Eliminate family disruption • No return to drug use

27. Although, the treatment community is feeling the ShiftLet’s Review the process….

28. Detox/ Inpatient Detox/ Outpatient Short-term Residential Treatment Long-term Residential Treatment Sober Living Residence Intensive Outpatient/Psychosocial Behavioral Treatment Medication Assisted Treatment Continuing Care Programs A Menu of Treatment Services

29. Acute System Response Admission Treatment… Discharge …One Type of Tx From Menu of Services Client Outcomes

30. What’s the Problem with this System? • Treatment effects usually don’t last very long after acute treatment stops • Clients who are not in some form of treatment or being monitored are at elevated risk for relapse

31. McLellan et al., 2000 compared substance use disorders with chronic illnesses (such as diabetes, hypertension, and asthma) and identified many similarities

32. How Similar in Heritability? Twin Study Estimates Eye Color 1.00 Asthma (adult only) .35 - .70 Diabetes (insulin dep) .70 - .95 (males) Hypertension .25 - .50 (males) Alcohol (dependence) .55 - .65 (males) Opiate (dependence) .35 - .50 (males)

33. 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 50 to 70% 50 to 70% 40 to 60% 30 to 50% 20 10 0 Drug Addiction Type I Diabetes Asthma Hypertension Sneak Peak at Similar Relapse Rates McLellan et al., JAMA, 2000

34. Chronic Care Model Response Treatment Recovery Detox Residential OutpatientNTP Continuing Care/Support Services Weare well trained in the realm of the treatment stages…

35. Stage of Treatment 1. Detoxification Purpose: Stabilization=Safe/Adequate reduction of withdrawal symptoms -Physical/Emotional stabilization -Promote problem recognition -Engage patient into rehabilitation

36. Effective Strategies During Engagement in Rehabilitation • Counseling to Promote Transfer using NIATx Strategies • Motivational Interviewing • Voucher-Based Techniques • Medications

37. Stage of Treatment 2. Rehabilitation Purpose: Sustain stable abstinence -Teach self-management skills -Identify & reduce threats to progress -Medications (maintenance and relapse prevention) -Engage patient in continuing care

38. Chronic Care Model Response Treatment Recovery Detox Residential OutpatientNTP Continuing Care/Support Services Emphasis on: Continuity of Care

39. What is Continuity of Care? Extending treatment beyond acute care Detox Residential Treatment Outpatient/Psychosocial Behavioral Treatment Arrow =Referral/Transfer NO Clinical Discharge Sober Living Residence Continuing Care/Support Services

40. Where is the State of CA in this shift?

41. To find out… • One place to start is with the data: • What % of your clients who complete your treatment program are being referred/transferred to another level of care (continuity of care)?

42. Continuity of Care Patterns in CA Majority of clients only receive 1 service (level of care)

43. What about the county of Sonoma? • What do you think? • In terms of the % of clients who complete treatment and are referred/transferred to another level of care (continuity of care)…

44. Sonoma No. of Admissions 31% 25% 6% 10% 36% Tx Modality *

45. State No. of Admissions 11% 29% 21% 13% 30% Tx Modality

46. Transfers from Detox Fresno State Detox Total: 962 Detox Total: 26670 Destination Treatment Type *Transfers to NTP Detox = 4, Day Care Rehab = 71, Maintenance= 126 *Transfers to NTP Detox = 0, Day Care Rehab = 0

47. Sonoma Residential Total: 2154 Transfers from Residential State Destination Treatment Type Residential Total: 41,636 *Transfers to NTP Detox = 46, Maintenance= 98 *Transfers to NTP Detox = 2, Maintenance= 0

48. Sonoma Mean No. of Days in Tx (N=184) (N=636) (N=194) ( N=1191) ( N=2957) (N=706) (N= 6) (N=49) Drug Category *Other = barbiturates, PCP, inhalants, ecstasy, hallucinogens, club drugs, and other stimulants and tranquilizers

49. Sonoma Mean No. of Days in Tx (N=320) (N=2400) (N=983) (N=1970) (N=116) (N=134) Type of Tx Modality

50. What Does this pattern mean? These statistics highlight one of the most prominent challenges faced by the addiction treatment field today… …many people who enter treatment do not complete the necessary course of treatment required for success Why is this a backward approach?