The Five-Year Recovery Standardfor the Evaluation of

Substance Abuse Treatment

Treatment Track

Moderator: Connie M. Payne, Executive Officer, Department of Specialty Courts, Kentucky Administrative Office of the Courts,and Member, Operation UNITE Board of Directors

Nora D. Volkow, MD, Director National Institute on Drug Abuse

www.drugabuse.gov

Robert L. DuPont, MD, PresidentInstitute for Behavior and Health, Inc.

www.ibhinc.org

Disclosures

• Robert L. DuPont, MD wishes to disclose that he was Vice President of Bensinger, DuPont & Associates (1982-2015) and Chairman of its subsidiary Prescription Drug Research Center (2003-2015). Content will be presented in a fair and balanced manner.

• Nora D. Volkow, MD has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership

interest: Starfish Health (spouse)

– Robert DuPont – Employment: Bensinger, DuPont & Associates-Prescription Drug Research Center

Learning Objectives

1. Explain the brain science of addiction which has direct implications for the treatment of substance use disorders.

2. Describe the physician health program (PHP) model of care management.

3. Advocate a five-year recovery standard for the evaluation of substance use disorder treatment.

The Neurobiology of ADDICTION

Nora D. Volkow, M.D.

Director

@NIDAnews

National Institute

on Drug Abuse

Natural & Drug Reinforcers IncreaseDopamine in NAc

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Active cocaine abusers showed a marked reduction in

MPH-induced DA increases and in its reinforcing effects

Volkow et al., Mol Psychiatry 2014

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MP increased DA in controls (p<0.001) whereas in cocaine abusersthe effects were minimal and only significant in VS (p<0.05)

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DA D2 Receptors

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Dopamine D2 Receptors are Lower in Addiction

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Neuro Learn Mem 2002.

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Over-expression of D2 receptors in rats markedly reducesalcohol intake

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Thanos et al., Alcohol Clin Exp Res.

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Non-Addicted Brain Addicted Brain

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Mu opiate receptors in Nucleus Accumbens (Nac)

Mu Opiate Drugs (Heroin, Hydrocodone, Morphine)

Increase DA in NAc

Nestler, Nature Neurosci, 2005

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Brain glucose metabolism is reducedin frontal cortex of cocaine abusers

Controls CocaineAbusers

In Cocaine Abusers MP-induced DA Increases In VS, While Very Blunted,

Triggered Craving

Volkow et al Mol Psychiatry 2014.

DA

Well-Known Obstacles To Addiction Treatment

• Most people with substance use disorders (SUDs) do not think that they have a disorder and they do not want treatment

• Most patients referred to treatment do not enter treatment

• Many patients who enter treatment drop out before completion

• Relapse after treatment is the usual outcome of treatment

Today’s Treatment Paradigm

• Addiction is a lifelong, potentially life-threatening disorder, while treatment is stand-alone, short-term episodes of care

• Patients are often treated for one substance at a time (e.g., treatment focused on opiate use may not address other substance use)

• Many patients continue to use alcohol and other drugs while in treatment (i.e., harm reduction)

3 Missing Elements

1. Definition of long-term recovery as the goal of all treatment and post-treatment interventions

2. Provision of sustained post-treatment monitoring and professional and peer support

3. Insistence by others around the patients on sustained abstinence as crucial for those with SUDs

ACA & Parity Will Lead to Shifts in SUD Treatment

• From acute, limited programmatic care to personalized sustained care of chronic illness

• More benefits for SUD treatment

• Adoption of chronic care model through proactive team treatment, multiple interventions and regular monitoring will lead to:

– Long-term accountability for health care system

– Stable, long-term recovery for patients

Lessons from the Physician Health Programs (PHPs)

• PHPs extend the period of accountability for abstinence to five years

• Physicians in PHPs transition from treatment to home, return to work, utilize the skills they learned in treatment, while knowing that anyreturn to substance use produces serious consequences

• Immersion in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA)

PHP SUD Care

• Zero tolerance for any substance use with frequent random drug tests and immediate, serious consequences for any missed or positive drug tests– Including the risk of losing their licenses to practice

medicine

• Evaluation and intervention

• Monitoring contract, usually for 5 years

• Formal treatment

• Long-term monitoring and support

PHP Longitudinal Study Results

• 904 physicians admitted to 16 PHP programs; 802 in 5-year follow-up:

– 64.2% (515) Completed contract

– 16.4% (132) Extended contract

– 19.3% (155) Failed to complete contract

PHP Results

• Large majority of physicians were practicing and were drug- and alcohol-free

• Of all physicians at 5 year follow-up (n=802):

– 78% of sample were licensed or working

– 4% had retired or left practice voluntarily

– 11% had their licenses revoked

– 3% unknown status

PHP Long-Term Drug Test Results

• Over the course of 5 years:

– 78% of all physicians had zero positive drug tests

– 14% had only 1 positive test

– 3% had 2 positives tests

– 5% had 3 or more positives

Five-Year Recovery

• Five-year abstinence and recovery as a primary measure of outcomes can reshape treatment outcome research and clinical practice

• Routine, long-term monitoring of patient behavior and compliance to improve outcomes as part of patient-centered medical care

• Incorporating many elements of the PHP model into routine health care

• Five-year recovery rate permits all treatment programs to compete on a level playing field

Addressing the Issue of Leverage

• Five-year recovery is possible with strong support of people who care about those with SUDs

• Families are at the top of the list of who can provide the necessary leverage

• There are roles for health care and employers

• While nearly all physicians initially object to PHP care management, when they are in recovery they recognize that the PHPs saved their lives

Next Steps

• Research is needed to test a variety of models to assess five-year recovery outcomes

• Having standardized five-year outcomes for all treatment programs will give consumers and payers useful information

• Publicly available five-year recovery outcomes will create powerful incentives to substantially improve treatment outcomes

• This standard can help make recovery the expected outcome of treatment

Future Challenges

• Make recovery – not relapse – the expected outcome of SUD treatment

• Health care reform promoting active lifetime monitoring and management of chronic diseases

• Use PHP-like long-term care management widely for SUDs

• Use the five-year recovery standard to assess outcomes

Thank you!

Questions and Comments

Institute for Behavior and Health

• IBH is a 501(c)3 non-profit organization that develops strategies to reduce drug use

• For more information and resources, visit the IBH websites: www.IBHinc.org

www.StopDruggedDriving.org

www.PreventTeenDrugUse.org

www.PreventionNotPunishment.org

References + Resources

• DuPont, R. L., Compton, W. M. & McLellan, A. T. (2015). Five-year recovery: A new standard for

assessing effectiveness of substance use disorder treatment. Journal of Substance Abuse

Treatment, 58, 1-5.

• DuPont, R. L., McLellan, A. T., Carr, G., Gendel, M & Skipper, G. E. (2009). How are addicted

physicians treated? A national survey of physician health programs. Journal of Substance Abuse

Treatment, 37, 1-7.

• DuPont R. L., McLellan A. T., White W. L., Merlo L., and Gold M. S. (2009). Setting the standard for

recovery: Physicians Health Programs evaluation review. Journal for Substance Abuse Treatment,

36(2), 159-171.

• DuPont, R. L., Seppala, M. D. & White, W. L. (2015). The three missing elements in the treatment of

substance use disorders: lessons from the physician health programs. Journal of Addictive

Diseases, 35(1), 3-7.

• Institute for Behavior and Health, Inc. (2014). The New Paradigm for Recovery: Making Recovery –

and Not Relapse – the Expected Outcome of Addiction Treatment. Rockville, MD: IBH. Available:

http://ibhinc.org/pdfs/NewParadigmforRecoveryReportMarch2014.pdf

• Institute for Behavior and Health, Inc. (2014). Creating a New Standard for Addiction Treatment

Outcomes. Rockville, MD: IBH. Available:

http://ibhinc.org/pdfs/CreatingaNewStandardforAddictionTreatmentOutcomes.pdf

• McLellan, A. T., Skipper, G. E., Campbell, M. G. & DuPont, R. L. (2008). Five year outcomes in a

cohort study of physicians treated for substance use disorders in the United States. British Medical

Journal, 337:a2038.

The Five-Year Recovery Standardfor the Evaluation of

Substance Abuse Treatment

Treatment Track

Moderator: Connie M. Payne, Executive Officer, Department of Specialty Courts, Kentucky Administrative Office of the Courts,and Member, Operation UNITE Board of Directors

Nora D. Volkow, MD, Director National Institute on Drug Abuse

www.drugabuse.gov

Robert L. DuPont, MD, PresidentInstitute for Behavior and Health, Inc.

www.ibhinc.org