The Science of Recovery Management

1
The Science ofRecovery Management

• Michael L. Dennis, Ph.D.
• Chestnut Health Systems
• 720 W. Chestnut,
• Bloomington, IL 61701, USA
• E-mail mdennis_at_chestnut.org
• Presentation at 2007 National Association of
  Addiction Treatment Providers (NAATP)
  Conference, May 20-23, 2007, San Diego, CA. The
  opinions are those of the authors and do not
  reflect official positions of the association or
  government. Available on line at
  www.chestnut.org/LI/Posters or by contacting Joan
  Unsicker at 720 West Chestnut, Bloomington, IL
  61701, phone [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org. This
  presentation was supported by funds from NIDA
  grant no. R37-DA11323, and R01 DA15523 and
  SAMHSA/CSAT contract no. 270-2003-00006 . The
  opinions are those of the authors do not reflect
  official positions of the government or ATTCs.
  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
• Epidemiological data 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
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 Scott under review
4
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 Scott under review
5
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 Scott under review
6
The Majority Stay in Tx Less than 90 days
90
60
52
42
Median Length of Stay in Days
33
30
20
0
Outpatient
Intensive
Short Term
Long Term
Outpatient
Residential
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/teds02/2
002_teds_rpt_d.pdf .
7
Less Than Half Are Positively Discharged
100
90
Other
80
70
Terminated
60
Discharge Status
Dropped out
50
40
Completed
30
20
Transferred
10
0
Less than 10 are transferred
Outpatient
Intensive
Short Term
Long Term
Outpatient
Residential
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/teds02/2
002_teds_rpt_d.pdf .
8
Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity
Adolescents More likely to have externalizing
disorders
100
100
20
40
60
80
20
40
60
80
0
0
Health Distress
Internal Disorders
Adults more likely to have internalizing
disorders
External Disorders
Crime/Violence
Criminal Justice System Involvement
Adults
Adolescents
Exception
Dependent (n1221)
Dependent (n3135)
Abuse/Other (n385)
Abuse/Other (n2617)
Source GAIN Coordinating Center Data Set
9
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)

10
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
11
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)
12
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
plt.05 (different from 21)
10
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
13
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
plt.05 (different from 20)
0
30
25
20
15
10
5
0
Source Dennis et al 2005 (n1,271)
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
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)
15
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adults

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
16
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
17
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 (under review)
18
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 (under review)
19
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

20
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents


Incarcerated
3

(46 stable)
5
In the
12

In Recovery
Community

(62 stable)
Using


27
(75 stable)

7


7
19
26
7



In Treatment

Avg of 39 change status each quarter
(48 stable)

Source 2006 CSAT AT data set
21
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery Adolescents
Probability of Transitioning to Tx - Age (0.7)
Weeks in Cont. Environ. (1.4) Times
urine tested (1.7) Treatment Motivation (1.6)



In the
12

In Recovery
Community

(62 stable)
Using


(75 stable)



19
7



In Treatment

(48 v 35 stable)

Source 2006 CSAT AT data set
22
The Early Re-Intervention (ERI) Experiments
(Dennis Scott)
Funding Source NIDA grant R37-DA11323
23
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
24
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

25
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
26
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)
27
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)
28
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
29
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
30
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)
31
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

32
These studies provide converging evidence
demonstrating that

• substance use disorders are often chronic in the
  sense that they last for years and the risk of
  relapse is high
• the majority of people accessing publicly funded
  substance abuse treatment have been in treatment
  before, are likely to return, have a variety of
  co-occurring problems and may need several
  additional episodes of care before they reach a
  point of stable recovery.
• Yet over half do make it to recovery and the odds
  of getting to and staying in recovery can be
  improved with proactive management.
• Though we did not have time to go over them
  today, similar studies and findings are coming
  out with adolescents and young adults

33
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

34
Sources and Related Work

• American Psychiatric Association. (2000).
  Diagnostic and statistical manual of mental
  disorders (DSM-IV-TR) (4th - text revision ed.).
  Washington, DC American Psychiatric Association.
  
• Chan, Y.-F., Dennis, M. L., Funk, R. (in
  press). Prevalence and comorbidity of major
  internalizing and externalizing problems among
  adolescents and adults presenting to substance
  abuse treatment. Journal of Substance Abuse
  Treatment.
• Dennis, M.L., Chan, Y.-F., Funk, R. (2006).
  Development and validation of the GAIN Short
  Screener (GSS) for psychopathology and
  crime/violence among adolescents and adults.
  American Journal on Addictions, 15, 80-91.
• Dennis, M.L., Foss, M.A., Scott, C.K (under
  review). Correlates of Long-Term Recovery After
  Treatment. Evaluation Review.
• Dennis, M. L., Scott, C. K. (in press). 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.
• 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.DrugAbuseStatis
  tics.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.
• Office Applied Studies (2002). Analysis of the
  2002 National Survey on Drug Use and Health
  (NSDUH) on line at http//webapp.icpsr.umich.edu/c
  ocoon/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. (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.
• 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.