Managing Substance Use Disorders SUDS as a Chronic Condition

1
Managing Substance Use Disorders (SUDS) as a
Chronic Condition

• Michael L. Dennis, Ph.D.
• Chestnut Health Systems
• 720 W. Chestnut,
• Bloomington, IL 61701, USA
• E-mail mdennis_at_chestnut.org
• August 14, 2006
• Presentation at the UCLA Center for Advancing
  Longitudinal Drug Abuse Research (CALDAR)
• Summer Institute, Current Findings and Future
  Directions in Longitudinal Research Conference,
  Los Angeles, CA, August 14-16, 2006. This
  presentation was supported by funds from CALDAR
  and data from NIDA grant no. R37-DA11323, and R01
  DA15523 and SAMHSA/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_at_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
• Quantifying the patterns that demonstrate that
  substance use disorders are a chronic condition
• Examining the cycle of relapse, treatment,
  incarceration and recovery that characterize the
  course of this condition and what predicts
  transition
• Presenting 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

• 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 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 Scott under review
5
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
6
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
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, OR1.46, plt.05),
• in treatment 3 or more times (16 vs. 9,
  OR1.79, plt.05),
• assigned to intensive outpatient (15 vs. 6,
  OR2.52, plt.05)
• assigned to residential treatment (16 vs. 5,
  OR3.17, plt.05)
• (OAS, 2002 on line data at http//webapp.icpsr.um
  ich.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
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 .
9
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 .
10
Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity
Adol. 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
11
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

12
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
13
Survival Analysis

• Time frames related to age of use, treatment, and
  death were measured across all sources and waves
  of information (taking the earliest first use,
  treatment episode, and 12 month period of
  abstinence or death).
• Age at last use was defined as the age when a
  person first completed a period of 12 month
  abstinence or had died (35 or 2.6 of the people
  died in 3 years).
• Durations were estimated with Cox Proportional
  Hazards Regression
• censoring people who were in treatment or still
  using,
• censoring years past which we had less than 100
  people to make the estimate, and
• creating a 30 year window of observation on the
  trajectory of substance use disorders starting at
  the time of first use

14
Age Distributions
Predominately Adolescent onset
15
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)
16
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)
17
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)
18
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)
19
Over 55 Continued to Changed Status Between
Annual Follow-up Interviews (83 over 3 years)
100
90
80
In the
community
70
In Recovery
60
50
40
In Treatment
Incarcerated
30
20
In the
community
10
using
0
Inc.
Recovery
In Tx.
In the Community Using
(6)
(26)
(12)
(57)
20
The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery


Incarcerated

(37 stable)
In the

In Recovery
Community

(58 stable)
Using


(53 stable)






In Treatment

(21 stable)

Source Scott et al 2005
21
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) - 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
22
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.

23
The Early Re-Intervention (ERI) Experiments
(Dennis Scott)
Funding Source NIDA grant R37-DA11323
24
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
25
Need For Treatment Re-Intervention

• Eligibility Not already in treatment or
  incarcerated and living in the community
• Need Yes to at least one of the following
• During the past 90 days, have you used alcohol,
  marijuana, cocaine, or other drugs on 13 or more
  days?
• During the past 90 days, have you gotten drunk or
  been high for most of 1 or more days?
• During the past 90 days, has your alcohol or drug
  use caused you not to meet your responsibilities
  at work/school/home on 1 or more days?
• During the past week, had withdrawal symptoms
  when you tried to stop, cut down, or control your
  use?
• Do you feel that you need to return to treatment?
• During the past month, has your substance use
  caused you any problems?
• Note alpha gt .90

26
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

27
Modifications to RMC for ERI -2 included

• Switch to from off- to on-site urine monitoring
  with immediate feedback on results (before
  detailed questions) to allow to probing and
  improve identification
• 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

28
False Negative Rates by Time and Experiment
50
Any Drug Tested Reported
Any AOD Reported \b
Any AOD or Medication Reported \c
40
30
19
20
15
15
9
9
10
5
4
3
3
2
1
1
0
12 Months
24 Months
12 Months
24 Months
ERI 1 (n350)
ERI 1 (n313)
ERI 2 (n424)
ERI 2 (n424)
\a False negative defined as positive on the
substance(s) but reporting no use in the past
month \b Considers self report of above plus
alcohol,hallucinogens, PCP, other psychotopics,
inhalants, and other drugs \c Any of the above or
any prescribed medication related to substance
use, mental health or physicial health treatment
29
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
30
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 d0.21
10
Wilcoxon-Gehen
0
Statistic (df1)
180
270
360
450
540
630
90
0
2.78, p lt.05
Days to Re-Admission (from 3 month interview)
31
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)
18.86, p lt.0001
Days to Re-Admission (from 3 month interview)
32
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
56
60
Percentage
50
43
40
26
30
21
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
(d0.00)
(d -0.15)
(d -0.05)
(d0.01)
(d -0.30)
plt.05
33
ERI-2 Impact on Outcomes
Months 4-24
Final Interview
100
RMC
90
OM
RMC Broke the Run
76
80
75
Less Likely to be in Need of Treatment
68
67
70
60
54
Less Symptoms
Percentage
46
50
42
40
35
28
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 -0.29)
(d 0.23)
(d -0.23)
(d -0.29)
plt.05
34
As expected, 32 of individuals change status
between the beginning and end of the quarter (82
over 2 years)
End of Quarter
100
90
80
70
60
50
40
30
Incarcerated
20
10
0
Inc.
Recovery
In Tx.
In the Community Using
(5)
(42)
(12)
(41)
(3,136 quarterly transition Observations on 448
unique people)
Beginning of Quarter
35
Impact on Primary Pathways to Recovery (incarcerat
ion 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
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)
36
Other Variables That Lost Significance in
Multivariate Model

• Problem Recognition, External Pressure, Internal
  Motivation, Treatment Resistance
• Current Withdrawal, Number of Diagnosis,
  Emotional Problems, Illegal Activity,
  Homelessness
• Coming from a controlled environment
• Involvement with the Criminal Justice System,
  Mental Health, Health, or Training/School Systems
• Lifetime number of prior treatment, arrests
• Gender, Race, Age, Employment

37
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

38
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.

39
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

40
Other Emerging Recovery Support Initiatives

• Assertive Continuing Care (ACC
  http//www.chestnut.org/li/apss/CSAT/protocols/ )
• Interactive phone and web based monitoring and
  recovery support
• Self help groups
• Recovery homes
• Recovery High Schools Colleges
• Well-briety movement in Indian Country
• Recovery advocacy movement
• Network for the Improvement of Addiction
  Treatment (NIATx http//www.pathstorecovery.org/
  )
• Washington Circle Group (http//www.washingtoncirc
  le.org/) and other efforts to introduce
  performance monitoring

41
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.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.
• Dennis, M. L., Scott, C. K. (under review).
  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.
• 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. (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.