1

Managing Substance Use Disorders (SUDS) as a Chronic Condition

Michael L. Dennis, Ph.D. &Christy K Scott, Ph.D.

Chestnut Health Systems720 W. Chestnut,

Bloomington, IL 61701, USA E-mail: mdennis@chestnut.org

Presentation in the 4th Plenary Session: Life Cycle’s Impact on Service Delivery and on Policies

at the 48th International Council on Alcohol and AddictionsBudapest, Hungary, 23 October 2005

This presentation was supported by funds and data from NIDA grant no. R37-DA11323 and 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@chestnut.org or 309-820-3805. A copy of these slides will be posted at www.chestnut.org/li/posters

.

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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 1. Describing the prevalence and characteristics of this subset of

people 2. the course of these disorders, and 3. the results of two experiments designed to improve the ways in

which this condition is managed across time and multiple episodes of care.

4

Definition of Chronic SUD• While terms like substance use, abuse, dependence, and addiction are

frequently used interchangeably, state regulators, accreditation programs, clinical providers and more recently clinical researchers have become increasingly consistent in how they define chronic substance use disorders.

• 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” and “hazardous use”respectively 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)

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Severity of Past Year Substance Use/Disorders (2002 U.S. Household Population age 12+= 235,143,246)

Dependence 5%

Abuse 4%

Regular AOD Use 8%

Any Infrequent Drug Use 4%

Light Alcohol Use Only 47%

No Alcohol or Drug Use

32%

Source: 2002 NSDUH and Dennis et al forthcoming

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Problems Vary by Age

Source: 2002 NSDUH and Dennis et al forthcoming

0

10

20

30

40

50

60

70

80

90

100

12-13

14-15

16-17

18-20

21-29

30-34

35-49

50-64

65+

No Alcohol or Drug Use

Light Alcohol Use Only

Any Infrequent Drug Use

Regular AOD Use

Abuse

Dependence

NSDUH Age Groups

Severity CategoryAdolescent

OnsetRemission

Increasing rate of non-

users

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Higher Severity is Associated with Higher Annual Cost to Society Per Person

Source: 2002 NSDUH and Dennis et al forthcoming

$0$231 $231

$725$406

$0$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

No Alcohol orDrug Use

Light Alcohol

Use Only

AnyInfrequentDrug Use

Regular AODUse

Abuse Dependence

Median (50th percentile)

$948

$1,613

$1,078$1,309

$1,528

$3,058Mean (95% CI)

This includes people who are in recovery, elderly, or do not use

because of health problems Higher Costs

8

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%, OR=1.46, p<.05), – in treatment 3 or more times (16% vs. 9%, OR=1.79, p<.05),– assigned to intensive outpatient (15% vs. 6%, OR=2.52, p<.05) – assigned to residential treatment (16% vs. 5%, OR=3.17, p<.05)

(OAS, 2002 on line data at http://webapp.icpsr.umich.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).

9

Multiple Co-occurring Problems Contribute to Chronicity

0% 20%

40%

60%

80%

100%

Health Distress

Internal Disorders

External Disorders

Crime/Violence

Criminal JusticeSystem

Involvement

Dependent (n=1221)

Other (n=385)

0% 20%

40%

60%

80%

100%

Dependent (n=3135)

Other (n=2617)

Adolescents Adults

Source: GAIN Coordinating Center Data Set

Exception

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Substance Use Careers Last for Decades P

erce

nt

in R

ecov

ery

Years from first use to 1+ years abstinence

302520151050

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Median duration of

27 years(IQR: 18 to

30+)

Source: Dennis et al 2005 (n=1,271)

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Substance Use Careers are Longer, the Younger the Age of First Use

Per

cen

t in

Rec

over

y

Years from first use to 1+ years abstinence

302520151050

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: Dennis et al 2005 (n=1,271)

under 15*

21+

15-20*

Age

of

1st U

se G

rou

ps

* p<.05 (different from 21+)

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Substance Use Careers are Shorter the Sooner People get to Treatment

Per

cen

t in

Rec

over

y

Years from first use to 1+ years abstinence

302520151050

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: Dennis et al 2005 (n=1,271)

20+

0-9*

10-19*

Yea

rs t

o 1st

Tx

Gro

up

s

* p<.05 (different from 20+)

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It Takes Decades and Multiple Episodes of Treatment

Years from first Tx to 1+ years abstinence

2520151050

Median duration of 9 years

(IQR: 3 to 23) and 3 to 4

episodes of care

Per

cen

t in

Rec

over

y

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: Dennis et al 2005 (n=1,271)

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The Cyclical Course of Relapse, Incarceration, Treatment and Recovery

In the Community

Using (53% stable)

In Treatment (21% stable)

In Recovery (58% stable)

Incarcerated(37% stable)

6%

13%

28%

30%

8%

25%

31%

4%

44%7%

29%

7%

Treatment is the most likely path

to recovery

P not the same in both directions

Source: Scott et al 2005

15Source: Scott et al 2005

Predictors of Change Also Vary by Direction

In the Community

Using (53% stable)

In Recovery (58% stable)

13%

29%

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)

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)

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The Early Re-Intervention (ERI) Experiments

ERI 1 ERI 2Recruitment Recruited 448 from

Community Based Treatment in Chicago in 2000 (84% of eligible recruited)

Recruited 446 from Community Based Treatment in Chicago in 2004 (93% of eligible recruited)

Design Random assignment to Recovery Management Checkups (RMC) or control

Random assignment to Recovery Management Checkups (RMC) or control

Follow-Up Quarterly for 2 years (95-97% per wave)

Quarterly for 4 years (95 to 97% per wave)

Data Sources GAIN, CEST, Urine, Salvia

Staff logs

GAIN, CEST, CAI, Neo, CRI, Urine, Staff logs

Publication Dennis, Scott & Funk 2003; Scott, Dennis & Foss, 2005

Scott & Dennis, under review (12 month findings)

Funding Source NIDA grant R37-DA11323

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Sample Characteristics of ERI 1 & 2 Experiments

0% 20%

40%

60%

80%

100%

African American

Age 30-49

Female

Employed

Dependence

Prior Treatment

Residential Treatment

Other Mental Disorders

Homeless

Physical Health Problems

ERI 1 (n=448)

ERI 2 (n=446)

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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

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Modifications to RMC for ERI -2 included:

• Switch to on-site urine monitoring with immediate feedback to improve detection

• 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

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0%

20%

40%

60%

80%

100%F

ollo

w-u

p(9

6% a

vg)

Nee

ded

Tx

(45%

avg

)

Atte

nded

Lin

kage

(99%

avg

)

Agr

eed

to T

xA

sses

smen

t(4

8% a

vg)

Sho

wed

to T

xA

sses

smen

t(4

2% a

vg)

Sho

wed

to T

x(3

5% a

vg)

Sta

yed

in T

x 14

+ d

ays

(60%

avg

)

ERI 1MaxAvgMin

Adherence to Recovery Management Checkup (RMC) Protocol in ERI 1 vs. 2

Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis, forthcoming)

Generally averaged as well or better

Quality assurance and transportation assistance reduced the variance

ImprovedScreening

ERI 2

Improved Retention

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% Readmitted (Months 4-12)

Relative to Control clients, RMC clients were more likely to return to treatment

Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scot & Dennis, forthcoming

30%38%

22%

36%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ERI 1 (d=+.17)T ERI-2 (d=+.30)*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

*p<.05ERI 1 RMC ERI 2 Control ERI 2 RMCERI 1 Control

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Mean Days of Treatment Received (months 4-12)

20

28

17

30

0

10

20

30

40

50

ERI 1 (d=+.16) ERI-2 (d=+.28)*

0

10

20

30

40

50

ERI 1 OM ERI 1 RMC ERI 2 OM ERI 2 RMC *p<.05

RMC clients received more Total Days of Treatment

Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)

ERI 1 RMC ERI 2 Control ERI 2 RMCERI 1 Control

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% with any successive quarters in need of treatment

42% 42%

63%

54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ERI 1 (d= -.00) ERI-2 (d= -.23)*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ERI 1 OM ERI 1 RMC ERI 2 OM ERI 2 RMC *p<.05

RMC clients were less likely to haveSuccessive Quarters in Need of Treatment

Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)

ERI 1 RMC ERI 2 Control ERI 2 RMCERI 1 Control

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In Need of Tx (using in community) at 12 months

52% 50%

60%

47%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ERI 1 (d= -.07) ERI-2 (d= -.32)*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ERI 1 OM ERI 1 RMC ERI 2 OM ERI 2 RMC *p<.05

RMC clients were less likely to be in need of treatment at the end of 12 months

Source: ERI experiments (Dennis, Scott, & Funk 2003; Scott, Dennis, & Funk, 2005; Scott & Dennis forthcoming)

Every Quarter this difference has been growing; Hence our plans to go out 4 years

ERI 1 RMC ERI 2 Control ERI 2 RMCERI 1 Control

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Source: ERI experiments (Scott, Dennis, & Foss, 2005)

Impact on Primary Pathways to Recovery(incarceration not shown)

In the Communityy

Using (71% stable)

In Treatment (35% stable)

In Recovery (76% stable)

27%

5%

8%

33%

18%

17%

Transition to Tx - Freq. of Use (0.7)

+ Prob. Orient. (1.4)+ Desire for Help (1.6)

+ RMC (3.22)

Again the Probability of

Entering Recovery is Higher from

Treatment

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)

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Reprise

• There is clearly a subset of people for whom substance use disorder are a chronic condition that last for many years, is expensive, and confounded with a wide range of other problems.

• Shifting to a recovery management paradigm requires a better understanding of how people cycle through relapse, incarceration, treatment and recovery

• While the natural cycle may take almost a decade and 3 to 4 episodes of care – it can be experimentally altered with more proactive early intervention protocols.

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Implications

• We need to 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

• Need for changes in funding, licensure and accreditation to accommodate and encourage above

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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.DrugAbuseStatistics.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., 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/cocoon/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.