The Five-Year Recovery Standard for the Evaluation of Treatment

1. The Five-Year Recovery Standard
for 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, President
Institute for Behavior and Health, Inc.
www.ibhinc.org

2. 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.

3. 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

4. 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.

5. The Neurobiology of ADDICTION
Nora D. Volkow, M.D.
Director
@NIDAnews
National Institute
on Drug Abuse

6. Natural & Drug Reinforcers Increase
Dopamine in NAc
0
100
200
300
400
500
600
700
800
900
1000
1100
0 1 2 3 4 5 hr
Time After Amphetamine
%ofBasalRelease
AMPHETAMINE
0
50
100
150
200
0 60 120 180
Time (min)%ofBasalRelease
Empty
Box Feeding
Di Chiara et al.
FOOD
VTA/SN
nucleus
accumbens
frontal
cortex
Drugs of abuse increase DA in the
Nucleus Accumbens, which is believed
to trigger the neuroadaptions
that result in addiction

7. -10 0 10 20 30 40
-2
0
2
4
6
8
10
High
(0-10)
Intravenous MPH
(1 min)
DA and the Rewarding Effects of Drugs
in Humans
Volkow et al., JPET 291:409-415, 1999.
(% change Bmax/Kd)
DA increases induced by MPH were associated
with the“high”
TYROSINE
DA
DOPA
DA
DA
DA
DA
TYROSINE
DA
DOPA
DA
DA
DA
DADA DA DA
DA
DADA
RR
RRRR
raclopride
raclopride
DA
DA
methylphenidate

8. Repeated Drug Use Changes the Brain
Weakens the Brain Dopamine System
TYROSINE
DA
DOPA
DA
DA
DA
DA
DA
DA
REPEATED USE OF COCAINE OR OTHER DRUGS
REDUCES LEVELS OF DOPAMINE D2 RECEPTORS
TYROSINE
DA
DOPA
DA
DA
DA
DA DA DA
DA
DADA
DA
COCAINE
TYROSINE
DA
DOPA
DA
DA
DA
DA
DA
DA
Control Cocaine Abuser
PLEASURE

9. Cocaine abusers showed decreased
DA increases and reduced
reinforcing responses to MP
Normal Control
Cocaine Abuser
Methylphenidate-induced Increases in Striatal DA
in Controls and in Detoxified Cocaine Abusers
0
5
10
15
20
25
30
35
%ChangeBmax/Kd
Controls
(n=20)
Abusers
(n = 20)
P < 0.003
21%
9%
Volkow et al., Nature 386:830-833, 1997.
ControlsAbusers
HIGHSelfReport
0
2
4
6
8
10
P < 0.001

10. Active cocaine abusers showed a
marked reduction in
MPH-induced DA increases and in
its reinforcing effects
Volkow et al., Mol Psychiatry 2014
Cocaine abuser
Control subject
Placebo MPH
0
5
10
15
20
25
Controls
(n=17)
Abusers
(n=17)
%ChangeBmax/Kd
14% 3%
P < 0.001
2
4
6
8
10
Self-reportHigh
(1-10)
P < 0.001
Controls Abusers
High
Low
Reactivity of Dopamine System To Drug Consumption
in Actively Using Addicted Subjects

11. 2
13%
Control subjects
Cocaine abusers with CUE
Cocaine abusers with NEUTRAL
MP-Induced DA Change Controls vs Cocaine
Abusers (with and without cues)
P <0.001
MP increased DA in controls (p<0.001) whereas in cocaine abusers
the effects were minimal and only significant in VS (p<0.05)
P <0.05
P <0.05
VolkowetalMolPsychiatry2014

12. DA
DA
DA
DA DADA
DA
signal
Motivation & Executive
Control Circuits ACG
OFC
SCC
INHIBITORY
CONTROL
EXECUTIVE
FUNCTION
PFC
MOTIVATION/
DRIVETo test if in addicted
Subjects reduced DA
signaling was associated
with changes in brain
function we measured DA
D2 receptors and brain
glucose metabolism
(marker of brain
function).
DA D2 Receptors
Metabolism

13. Dopamine D2 Receptors are Lower in Addiction
Cocaine
Alcohol
Heroin
Meth
control addicted
Volkow et al.,
Neuro Learn Mem 2002.
1.5
2
2.5
3
3.5
4
4.5
15 20 25 30 35 40 45 50
DAD2Receptors
(RatioIndex)
20 25 30 35 40 45 50
1.6
1.8
2
2.2
2.4
2.6
2.8
3
3.2`
Bmax/K
d
Normal Controls
Cocaine Abusers

14. D2R Overexpression in Sprague Dawleys
Over-expression of D2 receptors in rats markedly reduces
alcohol intake
0
10
20
30
40
50
60
%ChangeD2R
Time (days)
4 6 8 10
p < 0.0005
p < 0.0005
p < 0.005
p < 0.10
D2RVector
0
-100
-80
-60
-40
-20
0
Time (days)
4 6 8 10
p < 0.001
p < 0.001
p < 0.01
0
DA D2 Levels
D2R Overexpression In Alcohol Preferring Rats
Thanos et al., Alcohol Clin Exp Res.
Thanos, PK et al., J Neurochem, 2001.

15. OFC
umol/100gr/min
30
40
50
60
70
80
90
2.9 3 3.1 3.2 3.3 3.4 3.5 3.6
D2 Receptors (BPND)
1. 5 2 2. 5 3 3. 5 4
25
30
35
40
45
50
D2 R VS
(B max /Kd )
1. 5 2 2. 5 3 3. 5 4
22
24
26
28
30
32
34
36
38
D2 R VS
(B max /Kd )
MetabolismOFC
(micromol/100g/min)
1. 5 2 2. 5 3 3. 5
30
35
40
45
50
D2 R VS
(B max /Kd )MetabolismPrefrontal
(micromol/100g/min)
30
35
40
45
50
55
60
65
1.8 2 2.2 2.4 2.6 2.8 3 3.2 3.4
Controls
Methamphetamine
Abusers
4
0
Controls Alcoholics
Control Cocaine Abuser
DA D2 receptors
Relationship Between Brain Glucose Metabolism
and Striatal D2 Receptors
Volkow et al., PNAS 2011 108(37): 15037-42.
ACC
40
45
50
55
60
Controls Abusers
micromol/100g/min
ACC
P < 0.01
40
45
50
55
60
Controls Abusers
micromol/100g/min
OFC
P < 0.005

16. 0.900
0.950
1.00
1.05
1.10
1.15
1.20
1.25
1.30
4.0 4.2 4.4 4.6 4.8 5.0
OFC
Relativemetabolism
CG
DA D2 Receptors and Relationship to Brain Metabolism
in Subjects with Family History for Alcoholism
D2R were associated with metabolism in
PREFRONTAL regions the disruption of which
results in impulsivity and compulsivity
0.75
0.80
0.85
0.90
0.95
1.00
1.05
4.0 4.2 4.4 4.6 4.8 5.0
Relativemetabolism
D2R (Bmax/Kd)Correlations between Metabolism and D2R P <0.005
Volkow et al. Arch Gen Psychiatry 2006.

17. Non-Addicted Brain Addicted Brain
Dorsal
Striatum
Motor cortex
Amygdala
Hippocampus
PFC
(ACC, DLPFC
BA44, lat OFC)
STOPNAc
VTA
Dorsal
Striatum
Motor
Cortex
Amygdala
Hippocampus
PFC
(ACC, inferior PFC,
lateral OFC)
GONAc
VT
A
Volkow et al PNAS 2011
Controlled behavior Automatic behavior

18. Mu opiate receptors in Nucleus Accumbens (Nac)
Mu Opiate Drugs
(Heroin, Hydrocodone, Morphine)
Increase DA in NAc
Nestler, Nature Neurosci, 2005
Opiates
Opiates

19. Expected Consequences of Reduced Striatal
D2R Signaling in Indirect Pathway
VTA
SN
Striatum
Thalamus
GPe
FRONTAL CORTEX
STN
SNR-
GPi
 inhibition
 inhibition
 excitation
 inhibition
 excitation
LOW D2 Receptors
Glucose
Metabolism
40
45
50
55
60
Controls Abusers
micromol/100g/min
ACC
P < 0.01
40
45
50
55
60
Controls Abusers
micromol/100g/min
OFC
P < 0.005
Volkow et al., PNAS 2011.
Brain glucose metabolism is reduced
in frontal cortex of cocaine abusers

20. Controls Cocaine
Abusers
In Cocaine Abusers MP-induced
DA Increases In VS, While Very Blunted,
Triggered Craving
Volkow et al Mol Psychiatry 2014.
DA

21. 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

22. 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)

23. 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

24. 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

25. 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 any
return to substance use produces serious
consequences
• Immersion in Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA)

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. Thank you!
Questions and Comments

35. 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

36. 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.

37. The Five-Year Recovery Standard
for 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, President
Institute for Behavior and Health, Inc.
www.ibhinc.org