Despite wider acceptance of addiction as a chronic brain disorder, systems of care continue to be primarily developed and defined by acute, time-limited treatments. This fragmented approach fails to provide the life-long management necessary to achieve sustained remission.
Data from the Massachusetts Information System, for example, reveals that 87 percent of patients admitted to detox units have previous admissions; over half have been there more than five times. Similar data exists for long term residential programs where 75 percent of patients have been there multiple times.
Yet, the existing system encourages and reimburses bed care while underinvesting in community-based care management. Anecdotal reports from providers indicate that patient transitions from inpatient to outpatient care are poor, ranging from to 25 percent to 50 percent. While the system surely is suffering from a temporary dearth of inpatient capacity, the greatly underemphasized problems are the absence of comprehensive community based continuing care management and the paucity of prevention, early identification and intervention.
For more than 40 years, addiction treatment has been defined and judged by the misplaced perception that a fixed amount or duration of treatment, such as a week in detox or a month in rehab, will “fix the problem.” If the patient regresses after leaving rehab, it is often attributed to the patient’s lack of readiness or to ineffective treatment.
Acute detox and rehab care are not the template for treatment of a lifetime chronic condition. Patients must be treated in a seamless array of services matched to the severity of their condition or need and that treatment must be sustained beyond a time limited episode.
Consider that opiate dependence is not limited to any single demographic group, and those most affected are young adults. In the last six years, Gosnold admissions for this age group have risen from 27 percent to 45 percent. Many young people are getting to treatment, and this is a good thing. However, closer examination of the data is not as encouraging.
We tracked a sample of 65 young patients during and after their detox treatment. Among them,
- 96 percent reported a supportive family, girl/boyfriend, or 12-Step colleague.
- 93 percent successfully completed their inpatient treatment.
- 91 percent accepted a referral to continue their treatment at another level of care.
Yet despite these positive indicators of motivation, follow-up contacts revealed that:
- Only 53 percent kept their initial continuing care appointment.
- Only 23 percent kept their second appointment.
- 13 percent had already regressed (resumed use) within 72 hours of discharge.
- 17 percent had regressed by the second call, seven to 10 days later.
The patients were motivated to seek treatment and remain drug free and were engaged in their care. They also had supportive family and others who cared about them. Yet, nearly one in five regressed within one week following discharge. We must find better approaches to improve remission rates and successfully bridge the gap from a detox or rehab treatment to community based care.
A better way
A more comprehensive, chronic disease management approach incorporates a range of community based elements of care that can improve remission rates and reduce rehospitalizations. And those elements are available now. We simply need to provide them to our patients.
In addition to traditional psycho-social interventions and 12-Step groups, the elements include recovery coaching and care management to help patients focus on recovery activities, navigate high risk situations, strengthen the recovery life, and extinguish the drinking and using lifestyle; medication assisted treatment; technology assisted recovery supports; family support and coaching; recovery socialization; and urine drug monitoring. These are only a few of the interventions that we can use to help patients and it is past the time when they should be standard elements of a plan of care.
Chronic disease management thinking is central to policy and care system development. Treatment, prevention, and management need to reside on a single continuum that eliminates the barrier of “program” thinking. We must no longer consider a patient “discharged” with its implied message that they are “finished” with treatment.
Many of the components of the continuum must be integrated into the mainstream of healthcare. Patients with this disease and those at greatest risk must be served in a system that enables them to be cared for at any point on the spectrum, be it a hospital, a doctor’s office, a clinic or a specialty treatment center.
In addition to the extended care management, we must incorporate features on a scale necessary to effect real change.
1. Integration with Primary and Specialty Medical Care
The isolation of addiction services reinforces its separateness from general medical care, thus perpetuating the crisis orientation. A shift to an integrated system will require a shift in resource allocation, workforce development, improved reimbursement mechanisms, and modifications in regulatory and licensing standards.
2. Addiction Specialists in Hospitals to Manage Patients undergoing Alcohol Withdrawal