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@chestnut.org or 309-820-3805.

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1. Identify some of the problems with acute care model of treatment

2. Describe the characteristics of chronic care models of treatment

3. Develop strategies for making treatment more consistent with a chronic care model

Goals of this Presentation are to

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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

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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?

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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?

Continued

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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?

Continued

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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?

Continued

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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?

Continued

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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

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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

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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)

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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.

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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

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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

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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

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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

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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)

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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.

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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

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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

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Normal

Cocaine Abuser (10 days)

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 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.

Brain Activity on PET Scan After Using CocaineBrain 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)

Even after 100 days of abstinence

activity is still low

22Image courtesy of Dr. GA Ricaurte, Johns Hopkins University School of Medicine

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Using(N=661)

1 to 12 ms(N=232)

1 to 3 yrs(N=127)

3 to 5 yrs(N=65)

5 to 8 yrs(N=77)

% Days of Psych Prob (of 30 days)

% Above Poverty Line

% Days Worked For Pay (of 22)

% of Clean and Sober Friends

% Days of Illegal Activity (of 30 days)

Other Aspects of Recovery by Duration of Abstinence of 8 Years

Source: Dennis, Foss & Scott (2007)

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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)

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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

Characteristics of Chronic Care Models of Treatment

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

1. Used triage to focus on the highest severity subgroup and/or an explicit target group

2. Chose a strong intervention protocol based on prior evidence

3. Used quality assurance to ensure protocol adherence and project implementation

4. Used proactive case supervision of individual

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Impact of the numbers of Favorable features on Recidivism (509 JJ studies)

Source: Adapted from Lipsey, 1997, 2005

Average Practice

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Crime/Violence and Substance Problems Interact to Predict Recidivism

Low

Mod.

High

LowMod

.High0%

20%

40%

60%

80%

100%

Source: CYT & ATM Data

12 m

onth

rec

idiv

ism

Crime/ Violence predicted recidivism

Substance Problem Severity predicted

recidivismKnowing both was the

best predictor

Substance Problem

Scale

Crime and Violence

Scale

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Crime/Violence and Substance Problems Interact to Predict Violent Crime or Arrest

Low

Mod.

High

LowMod

.High

Source: CYT & ATM Data

12 m

onth

rec

idiv

ism

T

o vi

olen

t cri

me

or a

rres

t

Substance Problem

Scale

Crime and Violence

Scale

0%

20%

40%

60%

80%

100%

Crime/ Violence predicted

violent recidivism

(Intake) Substance Problem Severity did

not predict violent recidivism

Knowing both was the best predictor

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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

Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004

NOTE: There is generally little or no differences in mean effect size between these brand names

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Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)

The effect of a well implemented weak program is

as big as a strong program implemented poorly

The best is to have a strong

program implemented

well

Thus one should optimally pick the strongest intervention that one can

implement wellSource: Adapted from Lipsey, 1997, 2005

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Number of Clinical Problems by Level of Care

39%50% 55%

67%78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OP IOP LTR MTR STR

0 to 1

2 to 4

5 or more

Source: CSAT 2007 AT Outcome Data Set (n=12,824)

The Severity of People is NOT the same across levels of care.

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0%10%20%30%40%50%60%70%80%90%

100%

Low (OR 1.0)

Mod.(OR=4.8)

High(OR=13.8)

NoneOneTwoThreeFourFive+

No. of Problems* by Severity of Victimization

Source: CSAT AT 2007 dataset subset to adolescent studies (N=15,254)

Those with high lifetime

levels of victimization

have 117 times higher odds of

having 5+ major

problems** (Alcohol, cannabis, or other drug disorder, depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity)

Severity of Victimization

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Recovery* by Level of Care:

* 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)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12

Per

cent

in P

ast

Mon

th R

ecov

ery* Outpatient (+79%, -1%)

Residential(+143%, +17%)

Post Corr/Res (+220%, +18%)

OP & Resid

Similar

CC better

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

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Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17)

Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 10 20 30 40 50 60 70 80 90

Days after Residential (capped at 90)

Per

cen

t of

Clie

nts

Cont.CareAdmis.

Relapse

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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)

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Assertive Continuing Care (ACC)Hypotheses

Assertive Continuin

g Care

General Continuin

g Care Adherence

Relative to UCC, ACC will increase General Continuing Care Adherence (GCCA)

Early Abstinence

GCCA (whether due to UCC or ACC) will be associated with higher rates of early abstinence

Sustained Abstinence

Early abstinence will be associated with higher rates of long term abstinence.

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ACC Improved Adherence

Source: Godley et al 2002, 2007

0% 10%

20%

30%

40%

50%

60%

70%

80%

Weekly Tx Weekly 12 step meetings

Regular urine tests

Contact w/probation/school

Follow up on referrals*

ACC * p<.05

90%

100%

Relapse prevention*

Communication skills training*

Problem solving component*

Meet with parents 1-2x month*

Weekly telephone contact*

Referrals to other services*

Discuss probation/school compliance*

Adherence: Meets 7/12 criteria*

UCC

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GCCA Improved Early (0-3 mon.) Abstinence

Source: Godley et al 2002, 2007

24%

36% 38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*)

Low (0-6/12) GCCA

43%

55% 55%

High (7-12/12) GCCA * p<.05

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Early (0-3 mon.) Abstinence Improved Sustained (4-9 mon.) Abstinence

Source: Godley et al 2002, 2007

19% 22% 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any AOD (OR=11.16*) Alcohol (OR=5.47*) Marijuana (OR=11.15*)

Early(0-3 mon.) Relapse

69%

59%

73%

Early (0-3 mon.) Abstainer * p<.05

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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.

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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.

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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.