Chronic Disease Recovery: Reimagining Addiction Treatment

1. Acute Care Model for a Chronic Disease Recovery Oriented Systems of Care OETAS Fall 2009

2. Past Models of Addiction • All pathology focused • Moral Model, Public Health Model, Disease Model

3. Past Models of Addiction • All based on acute models of care

4. Acute Care Model of Treatment Services are delivered in a uniform series of encapsulated activities • screening, • admission, • a single point-in-time assessment, • a short course of minimally individualized treatment, • Discharge and brief “aftercare”, followed by termination of the service relationship.

5. Acute Care Model • Focused on symptom elimination for a single primary problem • A professional expert directs and dominates decision-making throughout this process. • Services transpire over a short period of time. • pre-arranged, time-limited insurance payment designed specifically for addiction disorders and “carved out” from general medical insurance

6. Acute Care Model • At discharge, “cure has occurred:” long-term recovery is then viewed as self-sustainable without on-going professional assistance. • Evaluation of success occurs at a single point-in-time follow-up, typically just months after treatment. • Post-treatment relapse is viewed as the failure (non-compliance) of the individual, rather than potential flaws in the design of the treatment protocol.

7. Evidence from Pathology Acute Care Models • Low Treatment Compliance • 50% of outpatients drop out of treatment within one month • 40% of court-ordered patients do not complete treatment (Hubbard, Flynn, Craddock, & Fletcher, 2001); (Watkins, Pincus, Tanielian, & Lloyd, 2003)

8. Evidence from Pathology Acute Care Models • Relapse Rates are High • About 60% use drugs within six months following treatment discharge • About 45% apply for residential treatment within 12 months (Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989)

9. Conclusion of Pathology Acute Care Model: • Public expectations have not been met • Treatment is not very effective; or • We have the wrong model for the illness

10. Chronic Disease Characteristics • Influenced by genetic inheritance and other personal, family, and environmental risk factors • Can be identified and diagnosed using well validated screening questionnaires and diagnostic checklists

11. Chronic Diseases • behaviors begin as voluntary choices but become deeply ingrained patterns of behavior that are further exacerbated by neurobiological changes in the brain that weaken volitional control over these contributing behaviors • Are marked by patterns of onset that may be sudden or gradual

12. Chronic Diseases • Have a prolonged or permanent course that varies from person to person in intensity (mild to severe) and pattern (from constant to recurrent) • Are accompanied by risks of profound pathophysiology, disability, and premature death

13. Chronic Diseases • Have effective treatments, self-management protocols, peer support frameworks, and similar remission rates, but no known definitive cure • Often generate psychological responses that include hopelessness, low self esteem, anxiety, and depression • Generate excessive demands for adaptation by families and intimate social networks

14. Outcome in Addiction Treatment McLellan (2003). What's Wrong with Addiction Treatment?

15. Addiction/Chronic IllnessCompliance Rate Relapse Rate (O'Brien & McLellan, 1996)

16. Cost/ Benefit Ratio of Acute Care Model vs. Chronic Care Model for Heroin Users $37.72 Value of $ Spent $4.86 (Zarkin, et al, 2005)

17. Disconnect • If we (the practitioners of addiction treatment) really believed addiction was a chronic disorder, we would not: • view prior treatment as a predictor of poor prognosis (and grounds for denial of treatment admission);

18. Disconnect • convey the expectation that all clients should achieve complete and enduring sobriety following a single, brief episode of treatment;

19. Disconnect • punitively discharge clients for becoming symptomatic; • relegate post-treatment continuing care services to an afterthought;

20. Disconnect • terminate the service relationship following brief intervention; or • treat serious and persistent AOD problems in serial episodes of self-contained, unlinked interventions.

21. Treatment Renewal Movement • Addiction is best understood as a chronic illness • Addiction requires continuing care over a continuum of care for life

22. Treatment Renewal Movement • Chronic vs. Acute Model • Continuum of Care vs. Unit or Episode • Performance Measurement vs. Outcomes • Medication Assisted Treatments

23. Treatment Renewal Movement • Addiction treatment should adhere to proven practices and principles • Treatment is very effective when these ideas/principles are followed NIDA (1999)