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Transcript of Shifting the Treatment Paradigm to Managing Addiction as a Chronic Condition Michael Dennis, Ph.D....
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
[email protected] 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
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?
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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
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
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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)
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)
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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
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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)
25
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
26
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
27
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
29
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
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
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
31
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
32
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.
33
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
34
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
36
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
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 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.
39
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
40
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
41
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
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.