Understanding and Managing The Recovery Cycle

1
Understanding and Managing The Recovery Cycle

• Michael L. Dennis, Ph.D.
• and Christy K Scott, Ph.D.
• Chestnut Health Systems
• 720 W. Chestnut,
• Bloomington, IL 61701, USA
• E-mail mdennis_at_chestnut.org
• Presentation at the Second Betty Ford Institute
  (BFI) Conference Extending the Benefits of
  Addiction Treatment Practical Strategies for
  Continuing Care and Recovery. This presentation
  was supported by funds from NIDA grant no.
  R37-DA11323, and R01 DA15523. The opinions are
  those of the authors do not reflect official
  positions of the government or BFI. Please
  address comments or questions to the author at
  mdennis_at_chestnut.org or 309-820-3805. A copy of
  these slides will be posted at www.chestnut.org/li
  /posters and the conference website
• .

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 present
• The results of a 9 year longitudinal study to
  quantifying the chronic nature of substance
  disorders and how it relates to a broader
  understanding of recovery
• The results of two experiments designed to
  improve the ways in which recovery is managed
  across time and multiple episodes of care.

3
Pathways to Recovery Study (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.
• Substance Cocaine (33), heroin (31), alcohol
  (27), marijuana (7).
• 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 (Scott Dennis)

4
Pathways to Recovery Sample Characteristics
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
5
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
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
6
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
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
7
The Cyclical Course of Relapse, Incarceration,
Treatment and 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 et al 2005
8
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
Community

(58 stable)
Using


29
(53 stable)



Probability of Relapsing from Abstinence times
in treatment (1.21) - Female (0.58)
homelessness (1.64) - ASI legal composite
(0.84) number of arrests (1.12) - of sober
friend (0.82) - per 77 self help sessions
(0.55)





Source Scott et al 2005
9
Percent Sustaining Abstinence Through Year 8 by
Duration of Abstinence at Year 7
Even after 3 to 7 years of abstinence about 14
relapse
100
.
86
86
90
It takes a year of abstinence before less than
half relapse
80
66
70
60
Sustaining Abstinent through Year 8
50
36
40
30
20
10
0
1 to 12 months
1 to 3 years
3 to 5 years
5 years
(n157 OR1.0)
(n138 OR3.4)
(n59 OR11.2)
(n96 OR11.2)
Duration of Abstinence at Year 7
Source Dennis, Foss Scott (in press)
10
Other Aspects of Recovery by Duration of
Abstinence of 8 Years
100
90
80
70
60
50
40
30
20
10
0
Using
1 to 12 ms
1 to 3 yrs
3 to 5 yrs
5 to 8 yrs
(N661)
(N232)
(N127)
(N65)
(N77)
Source Dennis, Foss Scott (in press)
11
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.
• Recovery is broader than abstinence and often
  takes several years after initial abstinence

12
The Early Re-Intervention (ERI) Experiments
(Dennis Scott)
Funding Source NIDA grant R37-DA11323
13
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 (n448)
ERI 2 (n446)
Physical Health Problems
14
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

15
RMC Protocol Adherence Rate by Experiment
100
90
80
70
60
50
40
30
20
10
0
Treatment Need (30 vs. 44) d0.31
Follow-up Interview (93 vs. 96) d0.18
Showed to Assessment (30 vs. 42) d0.26
Showed to Treatment (25 vs. 30) d0.18
Agreed to Assessment (44 vs. 45) d0.02
Linkage Attendance (75 vs. 99) d1.45
Treatment Engagement (39 vs. 58) d0.43
ERI-1 ERI-2
lt-Average-gt
Range of rates by quarter P(H
RMC1RMC2)lt.05
16
ERI-1 Time to Treatment Re-Entry
100
90
80
70
(n221)
60 ERI-1 RMC
Percent Readmitted 1 Times
60
51 ERI-1 OM
(n224)
50
40
30
Revisions to the protocol
20
Cohen's d0.22
10
Wilcoxon-Gehen
0
Statistic (df1)
180
270
360
450
540
630
90
0
5.15, p lt.05
Days to Re-Admission (from 3 month interview)
17
ERI-2 Time to Treatment Re-Entry
Percent Readmitted 1 Times
(n221)
55 ERI-2 RMC
37 ERI-2 OM
(n224)
Cohen's d0.41
Wilcoxon-Gehen
Statistic (df1)
16.56, p lt.0001
Days to Re-Admission (from 3 month interview)
18
ERI-1 Impact on Outcomes
Months 4-24
Final Interview
100
RMC
90
OM
80
79
79
79
RMC Broke the Run
80
Less Likely to be in Need of Treatment
70
60
Percentage
44
50
40
34
33
27
30
21
21
20
10
0
of 630 Days
of 7 Subsequent
of 90 Days
of 11 Sx of
Still in need of Tx
Abstinent
Quarters in Need
Abstinent
Abuse/Dependence
(d0.04)
(d -0.19)
(d -0.05)
(d-0.02)
(d -0.21)
plt.05
19
ERI-2 Impact on Outcomes
Months 4-24
Final Interview
100
RMC
90
OM
RMC Broke the Run
76
76
80
Less Likely to be in Need of Treatment
68
68
70
57
60
Less Symptoms
49
Percentage
46
50
37
40
27
30
19
20
10
0
of 630 Days
of 7 Subsequent
of 90 Days
of 11 Sx of
Still in need of Tx
Abstinent
Quarters in Need
Abstinent
Abuse/Dependence
(d0.29)
(d -0.32)
(d 0.23)
(d -0.23)
(d -0.24)
plt.05
20
Impact on Primary Pathways to Recovery (incarcerat
ion not shown)
32 Changed Status in an Average Quarter

• 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
5
33

• 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)
21
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 identification, showing to
  treatment, and engagement for at least 14 days
  upon readmission helped to improve outcomes
• ERI 2 also demonstrated the value of on-site
  proactive urine testing versus the traditional
  practice of sending off urine for post interview
  testing

22
We still 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

23
Sources and Related Work

• Dennis, M.L., Foss, M.A., Scott, C.K (in
  press). An eight-year perspective on the
  relationship between the duration of abstinence
  and other aspects of recovery. Evaluation Review.
• Dennis, M. L., Scott, C. K. (in press). Managing
  addiction as a chronic but treatable condition.
  NIDA Addiction Science Clinical Practice.
• 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.
• Scott, C. K., Dennis, M. L. (under review).
  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., 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.