Shifting the Treatment Paradigm to Managing Addiction as a Chronic Condition

1
Shifting the Treatment Paradigm to Managing
Addiction as a Chronic Condition

• Michael Dennis, Ph.D.
• Chestnut Health Systems,
• Bloomington, IL
• Presentation at the Haymarket Center's 15th
  Annual Summer Institute On Addictions, Oakbrook
  Terrace, IL, June 9-11, 2009.. This presentation
  was supported by funds from NIDA grants no. R13
  DA027269, R01 DA15523, R37-DA11323 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.
  Please address comments or questions to the
  author at mdennis_at_chestnut.org or 309-820-3805.

2
Goals of this Presentation are to

• Identify some of the problems with acute care
  model of treatment
• Describe the characteristics of chronic care
  models of treatment
• Develop strategies for making treatment more
  consistent with a chronic care model

3
Agenda

• Virtual walk through clinical practice as usual
• A fearless appraisal of the strengths and
  weakness of the current systems
• A review of what we mean by saying substance use
  disorders are chronic
• Characteristics of Chronic Care models
• How we can improve practice in our own programs

4
Virtual walk through clinical practice

• Call Appointment
• Person or voicemail?
• Time on hold?
• What information collected? Is it Used?
• Appointment scheduled right away or after how
  long?
• Time from first contact to appointment?
• Limited or Flexible of appointment time?
• Implications for work, child care,
  transportation?
• Any common complements or complaints?
• Facility
• Transportation, parking, signage issues?
• Institution vs. warm feel, comfort, privacy?
• Self contained vs. having to move around?
• Any common complements or complaints?

5
Continued

• Intake
• Waiting room comfort, beverage, entertainment,
  time?
• Arrangements for family or friends?
• Exams, urine tests, other invasive procedures?
• Any information from initial call used/trusted?
• Open, rating or standardized assessment?
• Objectivity, Consistency and formal rules for
  diagnosis, placement and treatment planning?
• Speed of interpretation recommendations?
• Time to first treatment?
• Any intervening services or assistance?
• Time and linkage to first treatment plan?
• What are the most common recommendations?
• Any common complements or complaints?

6
Continued

• Treatment
• Scheduling flexibility
• Privacy, comfort,
• Once assigned is intake assessment used / trusted
  or are some or all of the assessment repeated in
  early treatment?
• How well are the actual treatment plan and
  services linked to assessment?
• Is their an orientation or motivational
  interviewing track everyone goes through in the
  beginning?
• Are there special tracks or phases?
• What happens if someone does not show for
  treatment the first time? Once? More than once?
• What happens if someone does not appear to be
  getting along with their primary counselor?
• What happens if someone continues to use?
• Any common complements or complaints?

7
Continued

• Continuing care
• How long does treatment usually last for the
  middle 50?
• How often are people recommended to transfer to
  another level of care or program? How often do
  they get there?
• How are clients referred to other services?
• How is it monitored whether they get them?
• Are these referrals passive or assertive?
• What happens if they do not show to the other
  level of care, program or service?
• Are there do not readmit lists, why are clients
  on them and how often does this happen?
• How often would you have a least one follow-up
  with someone 90 or more days after the initial
  treatment discharge?
• Any common complements or complaints?

8
Continued

• What would change if.
• The person calling in had been in treatment 5 or
  more times before?
• Had been in your program 5 or more times?
• Had been in your program 5 or more times in the
  last 12 months?
• Do you..
• Monitor whether the services recommended are
  actually delivered to a manual or clear quality
  standard beyond simple length of stay or paper
  work?
• Know the most common presenting needs of your
  clients and have evidenced based approaches to
  deal with them?
• Have formal training protocols for staff on
  assessment, treatment and other services you
  routinely provide?
• Know the profile of clients that you do well
  with, do ok with, do badly with?

9
Common Complaints

• Cold inadequate facilities and lack of privacy
• Poor staff engagement (vs. customer service)
• Burdensome procedures and process (e.g., having
  to wait, answering the same questions to
  different people, answering questions that did
  not seem linked to services received, information
  not being used)
• Failure to appreciate the complexity and
  interaction of multiple problems and their
  implications for what is needed/feasible
• Arbitrary decisions and consequences
• Lack of options and administrative discharge of
  people for confirming their diagnosis

10
Key Problem 1 Current Treatment System is
Insufficient

• Less than 1 in 10 people with abuse/dependence
  getting to treatment
• Less than 50 stay 50 days (7 weeks)
• Less the 25 stay the 3 months recommended by
  NIDA researchers
• Less than half have positive discharges
• After intensive treatment, less than 10 step
  down to outpatient care

11
Key Problem 2 Lack of Standardized Assessment
for

• Substance use disorders (e.g., abuse, dependence,
  withdrawal), readiness for change, relapse
  potential and recovery environment
• Common mental health disorders (e.g., conduct,
  attention deficit-hyperactivity, depression,
  anxiety, trauma, self-mutilation and suicidality)
• Crime and violence (e.g., inter-personal
  violence, drug related crime, property crime,
  violent crime)
• HIV risk behaviors (needle use, sexual risk,
  victimization)
• Child maltreatment (physical, sexual, emotional)

12
Key Problem 3 No or Inconsistent Use of
Placement Criteria

• In practice, programs primarily refer people to
  the limited range of services they have readily
  available.
• Knowing nothing about the person other than what
  door they walked through we can correctly predict
  75 (kappa.51) of the adolescent level of care
  placements.
• The American Society for Addiction Medicine
  (ASAM) has tried to recommend placement rules for
  deciding what level of care an adolescent should
  receive based on expert opinion, but run into
  many problems.

13
Key Problem 3 (continued)Examples of problems
with placement

• difficulty synthesizing multiple pieces of
  information
• inconsistencies between competing rules
• the lack of the full continuum of care to refer
  people to
• having to negotiate with the participant,
  families and funders over what they will do or
  pay for
• there is virtually no actual data on the expected
  outcomes by level of care to inform decision
  making related to placement

14
Key Problem 4 Need for Specific Protocols and
Services Related to

• Motivational Interviewing and other protocols to
  help them understand how their problems are
  related to their substance use and that they are
  solvable
• Need for residential, IOP and other types of
  structured environments to reduce short term risk
  of relapse
• Relapse Prevention
• Proactive urine monitoring
• Need for recovery coaches, recovery schools,
  recovery housing and other adolescent oriented
  self help groups / services
• Detoxification services and medication
• Tobacco cessation

15
Key Problem 4 (continued) Need for Specific
Protocols and Services Related to

• Need for specific protocols related to trauma,
  suicide ideation, and para-suicidal behavior
• Need for victimization or child maltreatment
  interventions (not just reporting protocols)
• HIV Intervention to reduce high risk pattern of
  sexual behavior
• Anger Management
• Psychiatric services related to depression,
  anxiety, ADHD, conduct disorder, and ASPD/BPD
• Work or School problems
• Family problems

16
Key Problem 5 Need for Tracks, Phases and
Continuing Care

• Over half of adults and a third of adolescents
  are returning to treatment (more than a quarter
  for the second or more time)
• We need to understand what did and did not work
  the last time and have alternative approaches
• We need tracks or phases that recognize that they
  may need something different or be frustrated by
  repeating the same material again and again
• We need to have better step down and continuing
  care protocols
• We need better protocols for linking people to
  on-going recovery support services

17
Current Paradigm of Acute Care Treatment and
Research

• Focus on initial assessment and placement
• Brief and/or short term single episodes of care
  focused primarily on substance use, motivation,
  cognition and coping skills
• Indirect focus on changing the social recovery
  environment (with TCs being a major exception)
• Minimal or no post-discharge check-ups
• Evaluation of outcomes over relatively short
  periods of time (6-12 months) with the
  expectation that improvements should continue
  after treatment (i.e., an acute care model)

18
The Rise of Chronic ConditionsFrom 1900 to 1999

• Medical advances in treating accidents and
  infectious diseases reduced their likelihood of
  being the cause of death from over 60 to under
  20.
• This led to a rise in chronic conditions (e.g.,
  heart disease, diabetes, cancer, respiratory
  illnesses, Alzheimer's) being the cause of death
  from under 20 to over 70.
• It is estimated that modifiable behaviors caused
  or exacerbated 48 or more of these chronic
  conditions
• This includes 22 who used tobacco, alcohol and
  other drugs and another 4 who engaged in
  behaviors that can be substance related (e.g.,
  sexual transmission, motor vehicle, fire arm)
• Source Mokdad et al 2004.

19
What do we mean by saying something is a chronic
condition?

• There are often multiple interacting biological,
  behavioral and environment factors associated
  with current and future severity
• The condition lasts over many years
• There is a large risk of relapse after treatment
  or initial periods of remission
• Multiple episodes of care are often required
• While treatment is typically more effective than
  no treatment, each episode is associated with a
  worse prognosis
• There are some who may require continuous
  treatment or support for the rest of their lives

20
Need for a Chronic Care Model for Managing
Addiction

• Many consumers and clinicians view substance use
  as a chronic relapsing condition.
• An emerging body of evidence from treatment
  epidemiology suggests that the typical pathway to
  recovery currently involves multiple episodes of
  care over many years.
• Among people admitted to publicly funded
  treatment reported in TEDS, for instance, 60 of
  the people had been been in treatment before
  (including 23 1x, 13 2xs, 7 3xs, 17 4 or
  more).
• There is a high risk of relapse after treatment
  and the prognosis gets worse with each readmission

21
Brain Activity on PET Scan After Using Cocaine
With repeated use, there is a cumulative effect
of reduced brain activity which requires
increasingly more stimulation (i.e., tolerance)
Normal
Cocaine Abuser (10 days)
Even after 100 days of abstinence activity is
still low
Cocaine Abuser (100 days)
Photo courtesy of Nora Volkow, Ph.D. Volkow ND,
Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey
SL. Long-term frontal brain metabolic changes in
cocaine abusers. Synapse 11184-190, 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 14169-177, 1993.
22
Image courtesy of Dr. GA Ricaurte, Johns Hopkins
University School of Medicine
23
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 (2007)
24
Sustained Abstinence Also ReducesThe Risk of
Death
Users/Early Abstainers more likely to die in
the next 12 months
It takes 4 or more years of abstinence for risk
to get down to community levels
-
(Matched on Gender, Race Age)
Source Scott, Dennis, Simeone Funk
(forthcoming)
25
Characteristics of Chronic Care Models of
Treatment

• Customer service and structured/firm but non
  confrontational
• Assertive outreach, engagement, continuing care,
  and follow-up
• Placement into tracks, phases or services that
  take into account prior services and the past
  response to treatment
• Increased focus on multiple problems, services
  and systems
• Increased focus on monitoring adherence and
  adjusting intervention
• Use of checkups and early re-intervention
• Consistent assessment and records over multiple
  episodes of care

26
Meta analyses and Implementation Science Suggest
that Major Predictors of Bigger Effects are

• Used triage to focus on the highest severity
  subgroup and/or an explicit target group
• Chose a strong intervention protocol based on
  prior evidence
• Used quality assurance to ensure protocol
  adherence and project implementation
• Used proactive case supervision of individual

27
Impact of the numbers of Favorable features on
Recidivism (509 JJ studies)
Average Practice
Source Adapted from Lipsey, 1997, 2005
28
Crime/Violence and Substance Problems Interact
to Predict Recidivism
12 month recidivism
100
80
60
40
20
Crime and Violence Scale
Substance Problem Scale
0
High
High
Mod.
Mod.
Low
Low
Source CYT ATM Data
29
Crime/Violence and Substance Problems Interact
to Predict Violent Crime or Arrest
12 month recidivism To violent crime or arrest
Crime and Violence Scale
Substance Problem Scale
High
High
Mod.
Mod.
(Intake) Substance Problem Severity did not
predict violent recidivism
Low
Low
Source CYT ATM Data
30
Cognitive Behavioral Therapy (CBT) Interventions
that Typically do Better than Usual Practice in
Reducing Recidivism (29 vs. 40)

• Aggression Replacement Training
• Reasoning Rehabilitation
• Moral Reconation Therapy
• Thinking for a Change
• Interpersonal Social Problem Solving
• MET/CBT combinations and Other manualized CBT
• Multisystemic Therapy (MST)
• Functional Family Therapy (FFT)
• Multidimensional Family Therapy (MDFT)
• Adolescent Community Reinforcement Approach
  (ACRA)
• Assertive Continuing Care

NOTE There is generally little or no
differences in mean effect size between these
brand names
Source Adapted from Lipsey et al 2001, Waldron
et al, 2001, Dennis et al, 2004
31
Implementation is Essential (Reduction in
Recidivism from .50 Control Group Rate)
Thus one should optimally pick the strongest
intervention that one can implement well
Source Adapted from Lipsey, 1997, 2005
32
Number of Clinical Problems by Level of Care
The Severity of People is NOT the same across
levels of care.
Source CSAT 2007 AT Outcome Data Set (n12,824)
33
No. of Problems by Severity of Victimization
Those with high lifetime levels of victimization
have 117 times higher odds of having 5 major
problems
Severity of Victimization
(Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD,
victimization, violence/ illegal activity)
Source CSAT AT 2007 dataset subset to
adolescent studies (N15,254)
34
Recovery by Level of Care
100
Outpatient (79, -1)
90
Residential(143, 17)
80
Post Corr/Res (220, 18)
70
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)
35
Findings from the Assertive Continuing Care
(ACC) Experiment

• 183 adolescents admitted to residential substance
  abuse treatment
• Treated for 30-90 days inpatient, then discharged
  to outpatient treatment
• Random assignment to usual continuing care (UCC)
  or assertive continuing care (ACC)
• Over 90 follow-up 3, 6, 9 months post
  discharge

Source Godley et al 2002, 2007
36
Time to Enter Continuing Care and Relapse after
Residential Treatment (Age 12-17)
100
90
80
70
Relapse
60
Percent of Clients
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source Godley et al., 2004 for relapse and 2000
Statewide Illinois DARTS data for CC admissions
37
ACC Enhancements

• Continue to participate in UCC
• Home Visits
• Sessions for adolescent, parents, and together
• Sessions based on Adolescent Community
  Reinforcement Approach (A-CRA) manual (Godley,
  Meyers et al., 2001)
• Case Management based on ACC manual (Godley et
  al, 2001) to assist with other issues (e.g., job
  finding, medication evaluation)

38
Assertive Continuing Care (ACC)Hypotheses
Assertive Continuing Care
39
ACC Improved Adherence
100
20
30
10
40
50
60
70
80
90
0
Weekly
Tx
Weekly 12 step meetings
Relapse prevention
Communication skills training
Problem solving component
Regular urine tests
Meet with parents 1-2x month
Weekly telephone contact
Contact w/probation/school
Referrals to other services
Follow up on referrals
Discuss probation/school compliance
Adherence Meets 7/12 criteria
Source Godley et al 2002, 2007
40
GCCA Improved Early (0-3 mon.) Abstinence
100
90
80
70
60
50
38
36
40
30
24
20
10
0
Any AOD (OR2.16)
Alcohol (OR1.94)
Marijuana (OR1.98)
Low (0-6/12) GCCA
Source Godley et al 2002, 2007
41
Early (0-3 mon.) Abstinence Improved Sustained
(4-9 mon.) Abstinence
100
90
80
70
60
50
40
30
22
22
19
20
10
0
Any AOD (OR11.16)
Alcohol (OR5.47)
Marijuana (OR11.15)
Early(0-3 mon.) Relapse
Source Godley et al 2002, 2007
42
Post script on ACC

• The ACC intervention improved adolescent
  adherence to the continuing care expectations of
  both residential and outpatient staff doing so
  improved the rates of short term abstinence and,
  consequently, long term abstinence.
• Despite these gains, many adolescents in ACC (and
  more in UCC) did not adhere to continuing care
  plans.
• The ACC1 main findings are published and findings
  from two subsequent experiments are currently
  under review
• CSAT is currently replicating ACRA/ACC in 32
  sites
• The ACC manual is being distributed via the
  website and the CD.

43
To further improve the effectiveness of substance
abuse treatment, we need to

• identify and address the complex array of
  co-occurring problems that can impede sustained
  recovery,
• move beyond a system of passive referrals for
  co-occurring problems to an integrated and
  assertive system of care,
• proactively monitor patients after the
  traditional points of discharge, help them with
  long term recovery management, and promote early
  re-intervention when appropriate, and
• generally shift the paradigm of clinical models
  from an acute care approach to models that
  effectively manage chronic substance use
  disorders.

44
Policy and Research Implications

• Change systems of care and financial support
  mechanisms from acute to chronic care models.
• Identify the complex clusters of co-occurring
  problems both in terms of statistical factors
  and population subgroups.
• Develop effective recovery management strategies.
• Examine treatment effects across episodes of
  care.
• Examine the predictors of the trajectories for
  achieving and sustaining recovery over longer
  periods of time.
• Conduct more longitudinal research over the
  lifespan of the substance use and treatment
  careers.