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Understanding and Managing Addiction as a Chronic Condition

Michael L. Dennis, Ph.D.Chestnut Health Systems

Normal, IL

Presentation at the Congressional Addiction, Treatment, and Recovery Caucus Briefing, “Reducing Health Care Costs: Chronic Disease Management for Alcohol & Drug Problems,” June 11, 2009 from 1:00-3:00 p.m., 122 Cannon House Office Building. This presentation was supported by funds from and data from NIDA grants no. R01 DA15523, R37-DA11323, CSAT contract no. 270-07-0191 and several other authors/studies. It is available electronically at www.chestnut.org/li/posters. The opinions are those of the author and do not reflect official

positions of the government. I would like to thank Redonna Chandler, Wilson Compton, Mark Godley, Thomas Hilton, Randy Muck, Chris Scott, and Alan Sender, for their assistance

in preparing this presentation. Please address comments or questions to the author at mdennis@chestnut.org or 309-451-7801.

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The Goals of this Presentation are to:

1. Illustrate the chronic nature of substance use disorders

2. Examine the likelihood and nature of sustained recovery

3. Demonstrate the feasibility of using simple protocols like recovery checkups to improve long-term outcomes

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Normal

10 days of abstinence

100 days of abstinence

Source: Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 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 14:169-177, 1993.

Prolonged Substance Use Injures The Brain:Prolonged Substance Use Injures The Brain:Healing Takes Time Healing Takes Time

Normal levels of brain activity in PET

scans show up in yellow to red

After 100 days of abstinence, we can

see brain activity “starting” to recover

Reduced brain activity after regular

use can be seen even after 10 days

of abstinence

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Alcohol and Other Drug Abuse, Dependence and Problem Use Peaks at Age 20

Source: 2002 NSDUH and Dennis & Scott, 2007, Neumark et al., 2000

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+Other drug or heavy alcohol use in the past year

Alcohol or Drug Use (AOD) Abuse or Dependence in the past year

Age

Severity Category

Over 90% of use and

problems start between the ages of

12-20

It takes decades before most recover or die

Per

cent

age

People with drug dependence die an

average of 22.5 years sooner than those

without a diagnosis

5

8.9%

21.2%

7.3%

0.5% 1.0% 0.6%0%

5%

10%

15%

20%

25%

12 to 17 18 to 25 26+

Alcohol or Other Drug Abuse or Dependence Any Public or Private Treatment

Substance Use Disorders are Common,But Treatment Participation Rates Are Low

Source: OAS, 2006 – 2003, 2004, and 2005 NSDUH

Over 88% of adolescent and young adult treatment and

over 50% of adult treatment is publicly funded

Few Get Treatment: 1 in 17 adolescents,

1 in 22 young adults, 1 in 12 adults

Much of the private funding is limited to 30 days or less and authorized day by day

or week by week

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People Entering Publicly Funded Treatment Generally Use For Decades

Per

cen

t st

ill u

sin

g

Years from first use to 1+ years of abstinence302520151050

Source: Dennis et al., 2005

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

It takes 27 years before half reach 1 or more years of abstinence or die

7

Per

cen

t st

ill u

sin

g

Years from first use to 1+ years of abstinence

under 15

21+

15-20

Age of First Use

302520151050

Source: Dennis et al., 2005

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

60% longer

The Younger They Start, The Longer They Use

8

Per

cen

t st

ill u

sin

g

Years from first use to 1+ years of abstinence

Years to first

Treatment Admission

302520151050

Source: Dennis et al., 2005

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

20 or more years

0 to 9 years

10 to 19 years

57% quicker

The Sooner They Get The Treatment, The Quicker They Get To Abstinence

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After Initial Treatment…

• Relapse is common, particularly for those who: – Are Younger– Have already been to treatment multiple times – Have more mental health issues or pain

• It takes an average of 3 to 4 treatment admissions over 9 years before half reach a year of abstinence

• Yet over 2/3rds do eventually abstain• Treatment predicts who starts abstinence• Self help engagement predicts who stays abstinent

Source: Dennis et al., 2005, Scott et al 2005

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The Likelihood of Sustaining Abstinence Another Year Grows Over Time

36%

66%

86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 to 12 months 1 to 3 years 4 to 7 years

Duration of Abstinence

% S

usta

inin

g A

bsti

nenc

eA

noth

er Y

ear

.

After 1 to 3 years of abstinence, 2/3rds will make it another year

After 4 years of abstinence, about 86% will make it

another year

Source: Dennis, Foss & Scott (2007)

Only a third of people with

1 to 12 months of abstinence will

sustain it another year

But even after 7 years of abstinence, about

14% relapse each year

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Source: Dennis, Foss & Scott (2007)

What does recovery look like on average?

Duration of Abstinence1-12 Months 1-3 Years 4-7 Years

• More social and spiritual support• Better mental health • Housing and living situations continue to improve • Dramatic rise in employment and income • Dramatic drop in people living below the poverty line

• Virtual elimination of illegal activity and illegal income • Better housing and living situations • Increasing employment and income

• More clean and sober friends• Less illegal activity and incarceration • Less homelessness, violence and victimization • Less use by others at home, work, and by social peers

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Sustained Abstinence Also ReducesThe Risk of Death

Source: Scott, Dennis, Simeone & Funk (forthcoming)

-

Users/Early Abstainers more likely

to die in the next 12

months

The Risk of Death goes down with

years of sustained abstinence

It takes 4 or more years of abstinence for

risk to get down to

community levels

(Matched on Gender, Race & Age)

Dea

ths

in t

he

nex

t 12

mon

ths

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Other factors related to death rates

• Death is more likely for those who – Are older– Are engaged in illegal activity– Have chronic health conditions– Spend a lot of time in hospitals– Spend a lot of time in and out of substance abuse

treatment

• Death is less common for those who – Have a greater percent of time abstinent– Have longer periods of continuous abstinence– Get back to treatment sooner after relapse

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Recovery Management Checkups (RMC)

• Quarterly monitoring after treatment• 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

• Treatment Engagement Specialist

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Reducing Time from Relapse to Readmission

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0% 0 3 6 9 12 15 18 21

Months From Relapse to Readmission

Percent Readmitted 1+ Times37% Control

55% Checkups

Time from relapse to readmission

reduced by over 50%

Source: Scott & Dennis (2009)

50% more got back to

treatment

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Positive Consequences of Early Readmission

• Checkups and Early Readmission to Treatment were associated with: – Less substance use and problems– Longer periods of abstinence– More attendance and engagement in self help

activities• Above were associated with:

– Fewer HIV risk behaviours– Less illegal activity, arrests, and time

incarcerated– Fewer mental health problems– Less utilization and costs to society

Source: Scott & Dennis (2009)

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Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004

Cost of Substance Abuse Treatment Episode

$407

$1,249$1,132$1,384$2,486$2,907

$4,277$14,818

$0

$1

0,0

00

$2

0,0

00

$3

0,0

00

$4

0,0

00

$5

0,0

00

$6

0,0

00

$7

0,0

00

Screening & Brief Inter.(1-2 days)In-prison Therap. Com. (28 weeks)

Outpatient (18 weeks)Intensive Outpatient (12 weeks)

Treatment Drug Court (46 weeks)Residential (13 weeks)

Methadone Maintenance (87 weeks)Therapeutic Community (33 weeks)

$22,000 / year to incarcerate

an adult

$30,000/ child-year in foster care

$70,000/year to keep a child in

detention

• $750 per night in Detox• $1,115 per night in hospital • $13,000 per week in intensive care for premature baby• $27,000 per robbery• $67,000 per assault

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Investing in Treatment has a Positive Annual Return on Investment (ROI)

• Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested

• Treatment drug courts have an average ROI of $2.14 to $2.71 per dollar invested

Source: Bhati et al., (2008); Ettner et al., (2006)

This also means that for every dollar treatment is cut, we lose more money than we saved.

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Summary Points

• Addiction can be a chronic condition with high costs to the individual and society

• Getting people to recovery earlier requires getting people to treatment sooner after initial use and after relapse

• Simple protocols like recovery checkups can help achieve abstinence sooner and improve a wide range of outcomes

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Implications for Health Care Reform

• Finance addiction care similar to models for other chronic conditions

• Fund programs to get people into treatment early

• Expand capacity to reduce treatment gap

• Increase step down and continuing care

• Increase links to self help and recovery services

• Require several years of monitoring and early re-intervention when people relapse

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References• Bhati et al. (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders.  Washington, DC: Urban Institute.• Capriccioso, R. (2004).  Foster care: No cure for mental illness.  Connect for Kids.  Accessed on 6/3/09 from http://www.connectforkids.org/node/571• Chandler, R.K., Fletcher, B.W., Volkow, N.D. (2009).  Treating drug abuse and addiction in the criminal justice system: Improving public health and safety.  Journal American

Medical Association, 301(2), 183-190• Dennis, M.L., Foss, M.A., & Scott, C.K (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation

Review, 31(6), 585-612• Dennis, M. L., Scott, C. K. (2007). Managing Addiction as a Chronic Condition. Addiction Science & Clinical Practice , 4(1), 45-55.• 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.• Ettner, S.L., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., & Hser, Y.I. (2006).  Benefit Cost in the California Treatment Outcome Project: Does Substance Abuse

Treatment Pay for Itself?.  Health Services Research, 41(1), 192-213. • French, M.T., Popovici, I., & Tapsell, L. (2008). The economic costs of substance abuse treatment: Updated estimates of cost bands for program assessment and reimbursement.

Journal of Substance Abuse Treatment, 35, 462-469• Neumark, Y.D., Van Etten, M.L., & Anthony, J.C. (2000). Drug dependence and death: Survival analysis of the

Baltimore ECA sample from 1981 to 1995. Substance Use and Misuse, 35, 313-327.• Office of Applied Studies (2006). Results from the 2005 National Survey on Drug Use and Health: National Findings Rockville, MD:  Substance Abuse and Mental Health

Services Administration.  http://www.oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm#7.3.1  • Riley, B.B.,, Scott, C.K, & Dennis, M.L. (2008). The effect of recovery management checkups on transitions from substance use to substance abuse treatment and from treatment

to recovery.  Poster presented at the UCLA Center for Advancing Longitudinal Drug Abuse Research Annual Conference, August 13-15, 2008, Los Angles, CA.  www.caldar.org .

• Scott, C. K., & Dennis, M. L. (in press). 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., Simeone, R., & Funk R. (forthcoming). Predicting the likelihood of death of substance users over 9 years based on baseline risk, treatment and duration of abstinence. Chicago, IL: Chestnut Health Systems.

• 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.• Volkow N.D., Fowler J.S., Wang G-J., Hitzemann R., Logan J., Schlyer D., Dewey 5., Wolf A.P. (1993). Decreased dopamine D2 receptor availability is associated with reduced

frontal metabolism in cocaine abusers. Synapse 14:169-177.• Volkow, N.D., Hitzemann R., Wang C-I., Fowler I.S., Wolf A.P., Dewey S.L. (1992). Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190.