We keep repeating episodic care,
and we keep failing
Attributed to Einstein is the oft used quote defining insanity as doing the same thing over and over again expecting a different result. Step 2 of AA states that it is possible to be restored to sanity. If it is possible then, to become sane, we must do something different.
The “insanity” of addiction treatment today consists of stabilization of an acute phase of a disease rather than using a comprehensive definitive approach to the chronic disease it is known to be. Our methods are failing if measured by definitions that apply to other diseases. Yet we keep doing it again. We apply a model of care that creates the expectation that a long-term cure follows a single episode of care. Or worse, we accept the fact that this episode of care will most likely fail and lead to more episodes.
“Relapse-Treat-Repeat” are the instructions. During repeat treatment, insurance applies the same cost and time constraints as the first treatment that failed, and it is done again in the same way. Insanity.
The gap in what we know to be best practices for addiction and what is applied is enormous. This harkens to the days when years after tuberculosis was found to be caused by a bacteria, those suffering were still being confined to one of the thousands of “sanitoria” in the US with advertisements boasting “pristine courtyards and individual rooms.” Sound familiar?
TB was eventually found to be treatable with an antibiotic, but it was less available compared to widely available sanitoria confinements. So an inferior and often fatal form of treatment remained common for several more years. A gap in practice and policy led to many unnecessary deaths in those pristine courtyards.
We have available today highly successful systems of treatment for chronic diseases that have successful outcomes in treatment by any definition. These proven methods have become the standard of care for many chronic diseases, yet the chronic disease of addiction continues to hold a standard of care based on dogma, stigma and failed policies that support only acute care treatment for a chronic disease. Short stays in a “sanitorium” are sold as cures ignoring inferior results compared to chronic disease management. When properly applied “Recovery Management” has been proven to improve outcomes with addiction treatment similar to other chronic diseases.
Changes are necessary to move past our current failing practices. The most damning thing about our current success rates is that better proven alternatives are available, but we are not using them. A model applied to the treatment of professionals that has been available since the 1970’s was shown by Dr. Dupont in 2009 in the Journal of Substance Abuse Treatment to achieve a 78% five year success rate, and of those that relapsed, only 15% have a second relapse. This is one of many reports that tout the success of professionals treatment. Today’s usual methods lead to 50-90% of those completing treatment are readmitted within the first year after treatment.
The professional’s model can be applied to non-professionals as has been done successfully on smaller scales in Connecticut and Southeast Pennsylvania. There are those that would say that these results can not be obtained with “regular” people because the professionals have licenses to lose and are very educated. In my experience, these professionals are the most difficult to treat for these same reasons. The elements used as leverage for professionals in treatment, however, are no more powerful than a mother losing her children, a laborer losing his job and family, or any other number of tough consequences.
We can begin approaching the same level of success for everyone by applying three components included in Professional’s Programs that others do not normally receive:
- Use the same entity or person that initiated treatment throughout the course of treatment. This provides a facilitator from detox through the initial acute care. Then coordinated care is continued using recovery management principles that have been well defined. This entity could be an interventionist or case manager. This entity would not only aid in keeping the patient/client engaged, but will be instrumental in also creating an environment with families and/or jobs that maintain accountability similar to that provided by professional licensing Boards. This is the most important missing component right now, and in my opinion it is the reason Saitz et al did not find improvements in their study of chronic care for addiction published in JAMA 2013.
- Extend the time course of this oversight to five years. This time frame is a standard of care for other chronic diseases like cancer, diabetes or heart disease, and it is the length of time of a typical professional’s program with proven success.
- Objective accountability during this five year period provided by random urine drug testing, and previously agreed upon contracts between families or employers stating specific consequences for failures.
Implementation of these components is not as difficult discovering a revolutionary chemotherapy for cancer, or mobilizing world resources for treating a new strain of virus, yet failure to implement these components leads to just as devastating results. One hundred twenty will die today of this disease in the US, and many have been to treatment before.
A recent episode of 60 Minutes addressed the heroin epidemic in suburbia. It is unfortunate that this is what it takes to get real attention. The episode had several parents together to tell their stories. They are all from a central Ohio town who had recently lost loved ones to overdoses. Every single story included multiple episodes of attempted or failed treatments. Yet not once in the report was the question asked “how come none of these treatments worked?” Parents were following what they were told to do by the treatment community, yet they lost their child. This is the unspoken but most telling portion of the story to me. We can do better, and we must.
There is an independent coalition of treatment providers that have begun a grass roots effort to clean up industry practices and engage insurance payers for the implementation of this five year program. It can be found at ICOTP.com