Understanding and Managing Addiction as a Chronic Condition

1. Understanding and Managing Addiction as a Chronic Condition Michael L. Dennis, Ph.D. and Christy K Scott, Ph.D. Chestnut Health Systems Normal and Chicago, IL Presentation Mid-Atlantic Regional Dissemination Workshop: Cutting edge treatment. A CTN Regional Dissemination Conference, Baltimore, MD, on June 3-4, 2010.This presentation was supported by funds from and data from NIDA grants no. R01 DA15523, R37-DA11323, R01 DA021174, 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. We would like to thank Belinda Willlis , Rodney Funk, and Lilia Hristova, Lisa Nicholson, for their assistance in preparing this presentation. Please address comments or questions to the author at mdennis@chestnut.org or 309-451-7801. .p

2. The Goals of this Presentation are to: • Illustrate both the chronic nature of substance use disorders and the reality that sustained recovery is attainable • Describe the cyclical nature of addiction and how it relates to our broader understanding of recovery • Discuss the ways in which recovery extends beyond simple abstinence to include other key life areas. • Demonstrate the feasibility of managing addiction via regular checkups to improve long term outcomes • Examine the feasibility of extending the model to target other populations and impact a broader range of outcomes.

3. Over 90% of use and problems start between the ages of 12-20 It takes decades before most recover or die Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20 100 People with drug dependence die an average of 22.5 years sooner than those without a diagnosis 90 Percentage 80 70 60 Severity Category 50 Other drug or heavy alcohol use in the past year 40 30 Alcohol or Drug Use (AOD) Abuse or Dependence in the past year 20 10 0 65+ 12-13 14-15 16-17 18-20 21-29 30-34 35-49 50-64 Age Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000

4. pain Adolescent Brain Development Occurs from the Inside to Out and from Back to Front Photo courtesy of the NIDA Web site. From A Slide Teaching Packet: The Brain and the Actions of Cocaine, Opiates, and Marijuana.

5. Prolonged Substance Use Injures The Brain: Healing Takes Time Normal levels of brain activity in PET scans show up in yellow to red Normal Reduced brain activity after regular use can be seen even after 10 days of abstinence 10 days of abstinence After 100 days of abstinence, we can see brain activity “starting” to recover 100 days of abstinence Source: 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.

6. The effects on the brain can be long lasting(Serotonin Present in Cerebral Cortex Neurons) Still not back to normal after 7 years Reduced in response to excessive use Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

7. Most people who develop abuse/dependence Have substance related problems for years Once they have abuse or dependence, over half will have 12 or more years of AOD problems Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication

8. Yet Recovery is likely and better than average compared with other Mental Health Diagnoses SUD Remission Rates are BETTER than many other DSM Diagnoses 89% 89% 83% 77% 66% 58% 56% 48% 50% 40% 46% 39% 45% 31% 25% 20% 10% 10% 8% 8% 7% 18% 15% 12% 11% 10% 10% 8% 9% 7% 4% 4% 3% Past Year Recovery (no past year symptoms) Recovery Rate (% Recovery / % Dependent) 100% 90% 80% 70% 60% Median of 8 to 9 years in recovery 50% 40% 30% 15% 20% 13% 8% 10% 0% Drug Mood : Alcohol Anxiety : Conduct Any AOD Intermittent Explosive Defiant Oppositional Posttraumatic Stress Externalizing Any Attention Deficit Any Internalizing Lifetime Diagnosis Source: Dennis, Coleman, Scott & Funk forthcoming; National Co morbidity Study Replication

9. Few Get Treatment: 1 in 17 adolescents, 1 in 22 young adults, 1 in 12 adults Substance Use Disorders are Common, But U.S. Treatment Participation Rates Are Low Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Much of the private funding is limited to 30 days or less and authorized day by day or week by week Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

10. Cost of Substance Abuse Treatment Episode • $750 per night in Detox • $1,115 per night in hospital • $13,000 per week in intensive • care for premature baby • $27,000 per robbery • $67,000 per assault $70,000/year to keep a child in detention $22,000 / year to incarcerate an adult $30,000/ child-year in foster care Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004

11. Investing in Treatment has a Positive Annual Return on Investment (ROI)2 • Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested • Even the long term and more intensive Treatment Drug Courts programs have an average ROI of $2.14 to $2.71 per dollar invested This also means that for every dollar treatment is cut, we lose more money than we saved. Source: Bhati et al., (2008); Ettner et al., (2006)

12. Pathways to Recovery (CSAT # T100664, 270977011; NIDA DA15523) Source: Dennis et al., 2005; Scott et al 2005

13. 9- Year Pathways to Recovery Sample (N=1326) 100% 20% 40% 60% 80% 0% African American Age 30-49 Female Current CJ Involved Past Year Dependence Prior Treatment Residential Treatment Other Mental Disorders Homeless Physical Health Problems Source: Dennis et al., 2005; Scott et al 2005

14. Substance Use Careers Last for Decades 1.0 Median of 27 years from first use to 1+ years abstinence .9 Cumulative Survival .8 .7 Years from first use to 1+ years abstinence .6 .5 .4 .3 .2 .1 0.0 0 5 10 15 20 25 30 Source: Dennis et al., 2005

15. Substance Use Careers are Longer the Younger the Age of First Use Age of 1st Use Groups 1.0 .9 .8 Cumulative Survival .7 Years from first use to 1+ years abstinence .6 .5 under 15* .4 15-20* .3 .2 21+ .1 0.0 * p<.05 (different from 21+) 0 5 10 15 20 25 30 Source: Dennis et al., 2005

16. Substance Use Careers are Shorter the Quicker People Access Treatment Year to 1st Tx Groups 1.0 .9 .8 Cumulative Survival .7 Years from first use to 1+ years abstinence 20+ .6 .5 .4 .3 10-19* .2 .1 0.0 0-9* * p<.05 (different from 20+) 0 5 10 15 20 25 30 Source: Dennis et al., 2005

17. After Initial Treatment… • Relapse is common, particularly for those who: • Are Younger • Have already been to treatment multiple times • Have more mental health issues or pain • It takes an average of 3 to 4 treatment admissions over 9 years before half reach a year of abstinence • Yet over 2/3rds do eventually abstain Source: Dennis et al., 2005, Scott et al 2005

18. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery (Pathway Adults) P not the same in both directions 6% 7% 25% 30% 8% 28% 29% 4% 7% 44% 31% 13% Treatment is the most likely path to recovery Over half change status annually Incarcerated (37% stable) In the In Recovery Community (58% stable) Using (53% stable) In Treatment (21% stable) Source: Scott, Dennis, & Foss (2005)

19. 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 28% In Recovery Community (58% stable) Using 29% (53% stable) Probability of Sustaining Abstinence - times in treatment (0.83) + Female (1.72) - homelessness (0.61) + ASI legal composite (1.19) - number of arrests (0.89) + # of sober friend (1.22) + per 77 self help sessions (1.82) Source: Scott, Dennis, & Foss (2005)

20. 86% 66% 36% After 4 years of abstinence, about 86% will make it another year The Likelihood of Sustaining Abstinence Another Year Grows Over Time After 1 to 3 years of abstinence, 2/3rds will make it another year 100% . Only a third of people with 1 to 12 months of abstinence will sustain it another year 90% 80% 70% 60% % Sustaining Abstinence Another Year 50% 40% 30% 20% 10% 0% 1 to 12 months 1 to 3 years 4 to 7 years But even after 7 years of abstinence, about 14% relapse each year Duration of Abstinence Source: Dennis, Foss & Scott (2007)

21. What does recovery look like on average? Duration of Abstinence 1-12 Months 1-3 Years 4-7 Years • More clean and sober friends • Less illegal activity and • incarceration • Less homelessness, violence and • victimization • Less use by others at home, work, • and by social peers • Virtual elimination of illegal activity and illegal • income • Better housing and living situations • Increasing employment and income • More social and spiritual support • Better mental health • Housing and living situations continue to improve • Dramatic rise in employment and income • Dramatic drop in people living below the poverty line Source: Dennis, Foss & Scott (2007)

22. The Risk of Death goes down with years of sustained abstinence 15% 15% 14% 14% 13% 13% 12% 12% 11% 11% 10% 10% 9% 9% 8% 8% 7% 7% 6% 6% 4.5% 5% 5% 4% 4% 3% 3% 2% 2% 1% 1% 0% 0% Household Household Less than 1 Less than 1 1 1 - - 3 Years 3 Years 4 4 - - 8 Years 8 Years (OR=1.00) (OR=1.00) (OR=2.87) (OR=2.87) (OR=1.61) (OR=1.61) (OR=0.84) (OR=0.84) Death Rate by Years of Abstinence Users/ Early Abstainers 2.87 times more likely to die in the next year It takes 4 or more years of abstinence for risk to get down to community levels 11.9% 7.1% 3.8% Source: Scott, Dennis, Simeone & Funk (forthcoming)

23. 1.82 1.85 1.14 14.4 0.14 1.32 0.81 0.77 0.75 0.68 1.42 1.68 0.74 Relationship of Treatment, Abstinence and Death Age in Decades - Intake Chronic Condition - Intake Illegal Acts for $ -Intake Years to Mortality % Time in PH Hospital - Months 7-96 No of SA Treatment Episodes Months 0-6 Years of Abstinence % Time w Illegal Activity for $ - Months 7-96 No of SA Treatment Episodes - Months 7-96 % of Time in SA Treatment - Months 7-96 Good % of Time Abstinent Months 7-96 Bad Note: Numbers are Odds Ratio per decade, time or per 10% points Source: Scott, Dennis, Laudet, Simeone & Funk (under review)

24. Early Re-Intervention Experiment 1 (ERI-1) (ERI1; DA11323) Source: Dennis et al., 2003; Scott et al 2005

25. Early Re-Intervention Experiment 2 (ERI-2) (ERI1; DA11323) Source: Scott et al 2009, in press

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

27. Less Risk Behaviors, MH and Crime Less Successive Quarters Using Reduce Time to Re-admission Relative to Control, RMC will reduce the time from relapse to readmission The quicker the return to treatment, the less successive quarters using in the community The less quarters using in the community, the less HIV Risk Behaviors, Mental Health and Crime Problems Early Re-Intervention (ERI) Experiment and Hypotheses Monitoring and Early Re-Intervention Source: Dennis et al 2003, 2007; Scott et al 2005, in press

28. Recovery Management Checkups (RMC) • 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 • Treatment Engagement Specialist

29. 630-403 = -200 days ERI-1 Time to Treatment Re-Entry 100% 90% 80% 70% (n=221) 60% ERI-1 RMC* Percent Readmitted 1+ Times 60% 51% ERI-1 OM (n=224) 50% 40% 30% Revisions to the protocol 20% *Cohen's d=+0.22 10% Wilcoxon-Gehen 0% Statistic (df=1) 630 270 360 450 540 180 90 0 =5.15, p <.05 Days to Re-Admission (from 3 month interview)

30. ERI-1: Impact on Outcomes* More days of Abstinence Shorter time in community in Need of Treatment * p<.05 Source: Dennis, Scott & Funk (2003)

31. 3% 2% 16% 15% 9% 18% 17% 4% 5% 33% 27% 8% Again the Probability of Entering Recovery is Higher from Treatment ERI 1: Impact on Primary Quarterly Pathways to Recovery over 2 years 32% Changed Status in an Average Quarter Incarcerated (60% stable) In the In Recovery Community (76% stable) Using (71% stable) In Treatment (35% stable) Source: Scott et al 2005, Dennis & Scott, 2007

32. Transition to Recovery vs Continued Use • Freq. of Use (0.7) + Prob. Orient. (1.3) • Dep/Abs Prob (0.7) + Self Efficacy (1.2) • Recovery Env. (0.8) + Self Help Hist (1.2) • Access Barriers (0.8) + per 10 wks Tx (1.2) 18% In Recovery (76% stable) 8% Transition to Tx vs. Continued Use - Freq. of Use (0.7) + Prob. Orient. (1.4) + Desire for Help (1.6) + RMC (3.22) In Treatment (35% stable) ERI 1: Impact on Primary Quarterly Pathways to Recovery over 2 years In the Community Using (71% stable) Source: Scott et al 2005, Dennis & Scott, 2007

33. Quality assurance and transportation assistance reduced the variance ERI 2 Generally averaged as well or better than ERI 1 ImprovedScreening Improved Tx Engagement RMC Protocol Adherence Rate by Experiment 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Treatment Need (30 vs. 44%) d=0.31* Follow-up Interview (93 vs. 96%) d=0.18 Showed to Assessment (30 vs. 42%) d=0.26* Showed to Treatment (25 vs. 30%) d=0.18* Agreed to Assessment (44 vs. 45%) d=0.02 Linkage Attendance (75 vs. 99%) d=1.45* Treatment Engagement (39 vs. 58%) d=0.43* ERI-1 ERI-2 <-Average-> Range of rates by quarter * P(H: RMC1=RMC2)<.05 Source: Scott & Dennis (in press)

34. The size of the effect is growing every quarter 45-13 = -32 months (d=-.41) ERI-2: Time to Treatment Re-Entry at Year 4 RMC increases the odds of re-entering treatment over 4 years by 3.1 100% 90% 80% (n=198) 74% ERI-2 RMC* 70% Percent Readmitted 1+ Times 60% 48% ERI-2 OM (n=195) 50% 40% 30% 20% 10% 0% Wilcoxon-Gehen statistic (df=1) = 28.60, p<.001 OR=3.1, p<.05 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 Months from 1st Follow-up In Need for Treatment , Source: ERI 2

35. More days of abstinent RMC Increased Treatment Participation RMC Increased Treatment Participation Less likely to be in Need at 45m Fewer Seq. Quarters in Need 74% 71% 61% 47% 38% ERI-2: Impact on Outcomes at 45 Months OM RMC 100% 90% 80% 70% 67% 56% 60% 55% 50% Percentage 50% 41% 40% 30% 20% 10% 0% of 180 Days of 14 Subsequent Re-entered of 1260 Days Still in need of Tx at Mon 45 of Treatment Quarters in Need Treatment Abstinent (d=0.22)* (d= 0.26) * (d= 0.26)* (d= -0.32)* (d= -0.22) * * p<.05 Source: Scott & Dennis (2009)

36. * p<.05 63% 62% 49% ERI1&2: Impact Treatment Re-entry by Comorbidity and condition* RMC’s Impact on Treatment Participation was robust across levels of Comorbidity Returning to treatment varied by Comorbidity* OM RMC 100% 90% 80% 70% 60% 53% 47% Percentage 50% 40% 33% 30% 20% 10% 0% Substance Use + Internalizing + Externalizing Disorders (d=0.31) Substance Use + Internalizing Disorders (d=0.38) Substance Use Disorder (SUD) (d=0.23) Source: Rush, Dennis, Scott, Castel, & Funk (2008)

37. 4% 3% 13% 23% 8% 10% 24% 7% 6% 25% 35% 10% Again the Probability of Entering Recovery is Higher from Treatment ERI 2: Average Quarterly Transitions over 3 years 34% Changed Status in an Average Quarter Incarcerated (56% stable) In the In Recovery Community (58% stable) Using (75% stable) In Treatment (32% stable) Source: Riley, Scott & Dennis, 2008

38. In Recovery (58% stable) 25% 35% ERI 2: Average Quarterly Transitions over 3 years • Transition Tx to Recovery (vs. relapse) • Freq. of Use (0.01) + Wks Self Help (1.39) • Tx Resistance (0.79) +Self Help Act. (1.31) In the Community Using (75% stable) 10% Transition to Tx (vs use) - Tx Resistance (0.93) + Freq. of Use (25.30) + Desire for Help (1.23) + Wks of Self Help (1.51) + Self Help Act. (1.37) + Prior Wks of Tx (1.07) + RMC (2.08) In Treatment (32% stable) Source: Riley, Scott & Dennis, 2008

39. ERI-2: Indirect Effects of RMC on Other Outcomes RMC Direct Effects Other Indirect Effects Covariates Common path coefficients (male,female) coefficients Variance Explained Days to Tx re-entry (.08) (-.35,-.20) Random Assignment to RMC-WO +.29 Successive Quarters of Use (.09) (-.03,-.11) (+.01,+.14) Substance Problems +.26 +.43 Psychiatric Problems (.26) Psychiatric Problems (+.19,+.24) (+.12,+.03) +.40 HIV Risk Behaviors(.22) (+.39,+.53) HIV Risk Behaviors (+.16,+.49) +.19 Arrest/ (.13) Incarceration Illegal Activity (.15) Crime and Violence +.32 +.20 (+.27,+.30) Interpersonal Violence (.49) (+.21,+.13) With out Gender: CFI=.95, RMSEA=.048 With Gender Differences: CFI=.95, RMSEA=.028

40. RMC for Adolescents Feasibility Study (DA11323; SAMHSA 270-07-0191) Source: Dennis et al (forthcoming)

41. Cannabis Youth Treatment Experiment: Cumulative Recovery Pattern at 30 months 5% Sustained Recovery 37% Sustained 19% Intermittent, Problems currently in recovery 39% Intermittent, currently not in recovery The Majority of Adolescents Cycle in and out of Recovery Source: Dennis et al, forthcoming

42. CSAT Adolescent Treatment Data Set: Recovery* by Level of Care 100% Outpatient (+79%, -1%) 90% Residential(+143%, +17%) 80% Post Corr/Res (+220%, +18%) 70% CC better 60% Percent in Past Month Recovery* 50% OP & Resid Similar 40% 30% 20% 10% 0% 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)

43. More likely than adults to be diverted to treatment (OR=4.0) P not the same in both directions 3% 5% 10% 20% 24% 12% 27% 7 % 7% 19% 26% 7% Treatment is the most likely path to recovery More likely than adults to stay 90 days in treatment (OR=1.7) The Cyclical Course : Adolescents Incarcerated (46% stable) In the In Recovery Community (62% stable) Using (75% stable) Avg of 39% change status each quarter In Treatment (48% stable) Source: 2006 CSAT AT data set

44. The Cyclical Course : Adolescents • Probability of Going from Use to Early “Recovery” (+ good) • Age (0.8) + Female (1.7), • Frequency Of Use (0.23) + Non-White (1.6) • + Self efficacy to resist relapse (1.4) • + Substance Abuse Treatment Index (1.96) In the 12% In Recovery Community (62% stable) Using 27% (75% stable) Probability of from Recovery to “Using” (+ good) - Freq. Of Use (0.0002) + Initial Weeks in Treatment (1.03) - Illegal Activity (0.70) + Treatment Received During Quarter (2.00) - Age (0.81) + Recovery Environment (r)* (1.45) + Positive Social Peers (r) (1.43) • * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home • ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity.

45. The Cyclical Course : Adolescents • Probability of Going from Use to “Treatment” (+ good) • Age (0.7) + Times urine Tested (1.7), • + Treatment Motivation (1.6) • + Weeks in a Controlled Environment (1.4) In the Community Using (75% stable) 7% In Treatment (48 v 35% stable) Source: 2006 CSAT AT data set

46. Probability of Going to Using vs. Early “Recovery” (+ good) • - Baseline Substance Use Severity (0.74) + Baseline Total Symptom Count (1.46) • - Past Month Substance Problems (0.48) + Times Urine Screened (1.56) • - Substance Frequency (0.48) + Recovery Environment (r)* (1.47) • + Positive Social Peers (r)** (1.69) In the In Recovery Community (62% stable) Using (75% stable) 26% 19% • * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home • ** Proportion of social peers during transition period in school/work, treatment, recovery, and inverse of those using alcohol, drugs, fighting, or involved in illegal activity. In Treatment (48 v 35% stable) Source: 2006 CSAT AT data set The Cyclical Course : Adolescents

47. Probability of Going to Using vs. Early “Recovery” (+ good) + Recovery Environment (r)* (3.33) The Cyclical Course : Adolescents Incarcerated (46% stable) 10% 20% In the In Recovery Community (62% stable) Using (75% stable) * Average days during transition period of participation in self help, AOD free structured activities and inverse of AOD involved activities, violence, victimization, homelessness, fighting at home, alcohol or drug use by others in home Source: 2006 CSAT AT data set

48. Results from these studies provide converging evidence demonstrating that • Addiction has immediate and lasting effects on the brain. • Addiction is chronic in the sense that the risk of relapse persists many years after Tx participation. • Addiction is cyclical in that individuals cycle through periods of abstinence, relapse, treatment, and incarceration before achieving self-sustained recovery. • Recovery is more than abstinence, and requires improvements in many key life areas. • Recovery is common, predictable, and can be proactively managed – but relapse risk persists • Gender and multimorbidity are significant moderators for service needs and recovery resources

49. Next Steps • Multiple papers published and/or under review • Anticipating funding the Pathways funding this fall to continue following the cohort out 18 years post intake as they age into their 50s and 60s. • Just completed a 5 year follow-up wave for ERI to evaluate the impact of “removing” RMC and to evaluate 5 year HIV sero conversion • Evaluating the cost, cost-effectiveness and benefit-cost of RMC • Just finished recruitment for a 3 year randomized trial of RMC with women coming out of cook county jailing using RMC plus new components targeting HIV risk behaviors and criminal activity • Planning a pilot study of RMC with adolescents

50. References • Bhati et al. (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders.  Washington, DC: Urban Institute. • Capriccioso, R. (2004).  Foster care: No cure for mental illness.  Connect for Kids.  Accessed on 6/3/09 from http://www.connectforkids.org/node/571 • Chandler, R.K., Fletcher, B.W., Volkow, N.D. (2009).  Treating drug abuse and addiction in the criminal justice system: Improving public health and safety.  Journal American Medical Association, 301(2), 183-190 • Dennis, M.L., Coleman, V., Scott, C.K & Funk, R (forthcoming). The Prevalence of Remission from Major Mental Health Disorder in the US: Findings from the National Co morbidity Study Replication. • Dennis, M.L., Foss, M.A., & Scott, C.K (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612 • Dennis, M. L., Scott, C. K. (2007). Managing Addiction as a Chronic Condition. Addiction Science & Clinical Practice , 4(1), 45-55. • 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. • Ettner, S.L., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., & Hser, Y.I. (2006).  Benefit Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment Pay for Itself?.  Health Services Research, 41(1), 192-213. • French, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates of cost bands for program assessment and reimbursement. Journal of Substance Abuse Treatment, 35, 462-469 • Neumark, Y.D., Van Etten, M.L., & Anthony, J.C. (2000). Drug dependence and death: Survival analysis of the Baltimore ECA sample from 1981 to 1995. Substance Use and Misuse, 35, 313-327. • Office of Applied Studies (2006). Results from the 2005 National Survey on Drug Use and Health: National Findings Rockville, MD:  Substance Abuse and Mental Health Services Administration.  http://www.oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm#7.3.1  • Riley, B.B.,, Scott, C.K, & Dennis, M.L. (2008). The effect of recovery management checkups on transitions from substance use to substance abuse treatment and from treatment to recovery. Poster presented at the UCLA Center for Advancing Longitudinal Drug Abuse Research Annual Conference, August 13-15, 2008, Los Angles, CA. www.caldar.org . • Rush, B., Dennis, M.L., Scott, C.K, Castel, S., & Funk, R.R. (2008). The Interaction of Co-Occurring Mental Disorders and Recovery Management Checkups on Treatment Participation and Recovery. • Scott, C. K., & Dennis, M. L. (2009). 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., Dennis, M. L., & Funk, R.R. (2008). Predicting the relative risk of death over 9 years based on treatment completion and duration of abstinence . Poster 119 at the College of Problems on Drug Dependence (CPDD) Annual Meeting, San Juan, PR, June 16, 2008. Available at www.chestnut.org/li/posters . • 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. • Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. (1993). Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177. • Volkow, ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. (1992). Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190.