Understanding and Managing The Recovery Cycle

1. Understanding and Managing The Recovery Cycle Michael L. Dennis, Ph.D. and Christy K Scott, Ph.D. Chestnut Health Systems 720 W. Chestnut, Bloomington, IL 61701, USA E-mail: mdennis@chestnut.org Presentation at the Second Betty Ford Institute (BFI) Conference Extending the Benefits of Addiction Treatment: Practical Strategies for Continuing Care and Recovery. This presentation was supported by funds from NIDA grant no. R37-DA11323, and R01 DA15523. The opinions are those of the authors do not reflect official positions of the government or BFI. 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 and the conference website .

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 present • The results of a 9 year longitudinal study to quantifying the chronic nature of substance disorders and how it relates to a broader understanding of recovery • The results of two experiments designed to improve the ways in which recovery is managed across time and multiple episodes of care.

3. 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 (Scott & Dennis)

4. 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

5. 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% 0 5 10 15 20 25 30 Source: Dennis et al 2005 (n=1,271)

6. 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% 0 5 10 15 20 25 Source: Dennis et al 2005 (n=1,271)

7. The Cyclical Course of Relapse, Incarceration, Treatment and Recovery P not the same in both directions 6% 7% 25% 30% 8% 13% 29% 4% 7% 44% 31% 28% Treatment is the most likely path to recovery Over half change status annually Incarcerated (37% stable) In the In Recovery Community (58% stable) Using (53% stable) In Treatment (21% stable) Source: Scott et al 2005

8. 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) - ASI legal composite(0.84) + number of arrests (1.12) - # of sober friend (0.82) - per 77 self help sessions (0.55) Source: Scott et al 2005

9. Percent Sustaining Abstinence Through Year 8 by Duration of Abstinence at Year 7 Even after 3 to 7 years of abstinence about 14% relapse 100% . 86% 86% 90% It takes a year of abstinence before less than half relapse 80% 66% 70% 60% % Sustaining Abstinent through Year 8 50% 36% 40% 30% 20% 10% 0% 1 to 12 months 1 to 3 years 3 to 5 years 5+ years (n=157; OR=1.0) (n=138; OR=3.4) (n=59; OR=11.2) (n=96; OR=11.2) Duration of Abstinence at Year 7 Source: Dennis, Foss & Scott (in press)

10. 1-3 Years: Decrease in Illegal Activity; Increase in Psych Problems 5-8 Years: Improved Psychological Status 3-5 Years: Improved Vocational and Financial Status 1-12 Months: Immediate increase in clean and sober friend % of Clean and Sober Friens % Days of Illegal Activity (of 30 days) % Days Worked For Pay (of 22) % Days of Psych Prob (of 30 days) % Above Poverty Line 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 (N=661) (N=232) (N=127) (N=65) (N=77) Source: Dennis, Foss & Scott (in press)

11. 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. • “Recovery” is broader than abstinence and often takes several years after initial abstinence

12. The Early Re-Intervention (ERI) Experiments (Dennis & Scott) Funding Source NIDA grant R37-DA11323

13. 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 (n=448) ERI 2 (n=446) Physical Health Problems

14. 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

15. Quality assurance and transportation assistance reduced the variance ERI 2 Generally averaged as well or better than ERI 1 ImprovedScreening Improved Tx Engagement RMC Protocol Adherence Rate by Experiment 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Treatment Need (30 vs. 44%) d=0.31* Follow-up Interview (93 vs. 96%) d=0.18 Showed to Assessment (30 vs. 42%) d=0.26* Showed to Treatment (25 vs. 30%) d=0.18* Agreed to Assessment (44 vs. 45%) d=0.02 Linkage Attendance (75 vs. 99%) d=1.45* Treatment Engagement (39 vs. 58%) d=0.43* ERI-1 ERI-2 <-Average-> Range of rates by quarter * P(H: RMC1=RMC2)<.05

16. 630-403 = -200 days ERI-1 Time to Treatment Re-Entry 100% 90% 80% 70% (n=221) 60% ERI-1 RMC* Percent Readmitted 1+ Times 60% 51% ERI-1 OM (n=224) 50% 40% 30% Revisions to the protocol 20% *Cohen's d=+0.22 10% Wilcoxon-Gehen 0% Statistic (df=1) 630 270 360 450 540 180 90 0 =5.15, p <.05 Days to Re-Admission (from 3 month interview)

17. 100% The size of the effect is growing every quarter 90% 80% 70% 630-246 = -384 days 60% 50% 40% 30% 20% 10% 0% 630 270 360 450 540 180 90 0 ERI-2 Time to Treatment Re-Entry Percent Readmitted 1+ Times (n=221) 55% ERI-2 RMC* 37% ERI-2 OM (n=224) *Cohen's d=+0.41 Wilcoxon-Gehen Statistic (df=1) =16.56, p <.0001 Days to Re-Admission (from 3 month interview)

18. No effect on Abstinence/Symptoms 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% 60% Percentage 44% 50% 40% 34% 33% 27% 30% 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 (d=0.04) (d= -0.19) * (d= -0.05) (d=-0.02) (d= -0.21) * * p<.05

19. Significant Increase in Abstinence ERI-2: Impact on Outcomes Months 4-24 Final Interview 100% RMC 90% OM RMC Broke the Run 76% 76% 80% Less Likely to be in Need of Treatment 68% 68% 70% 57% 60% Less Symptoms 49% Percentage 46% 50% 37% 40% 27% 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 (d=0.29)* (d= -0.32) * (d= 0.23)* (d= -0.23)* (d= -0.24) * * p<.05

20. Again the Probability of Entering Recovery is Higher from Treatment Impact on Primary Pathways to Recovery (incarceration not shown) 32% Changed Status in an Average Quarter • 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% 33% 5% • 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)

21. 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 • ERI 2 also demonstrated the value of on-site proactive urine testing versus the traditional practice of sending off urine for post interview testing

22. We still 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

23. Sources and Related Work • Dennis, M.L., Foss, M.A., & Scott, C.K (in press). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review. • Dennis, M. L., Scott, C. K. (in press). Managing addiction as a chronic but treatable condition. NIDA Addiction Science & Clinical Practice. • 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. • Scott, C. K., & Dennis, M. L. (under review). 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., & 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.