William L. White1 and John F. Kelly
(1)
Lighthouse Institute, Chestnut Health Systems, Bloomington, IL, USA
William L. White
Email: bwhite@chestnut.org
Abstract
Severe alcohol and other drug problems typically take a chronic course and often require multiple episodes of intervention before stable recovery is achieved. The conceptualization of addiction as a chronic disorder has critical implications for the design, delivery, evaluation, and funding of addiction treatment. Yet, despite widespread acknowledgement that the nature and long-term course of addiction is similar to other chronic illnesses, such as hypertension and diabetes, it is still treated almost universally as an acute condition. This acute care model has been shaped by a number of influences, including the commercialization of addiction treatment and a system of managed behavioral health care, which have forced treatment into discrete, and ever-briefer, episodes of care. In this chapter, we address the shortfalls of the acute care model and contrast it with a model of sustained recovery management, which aims to remedy the mismatch between the chronic nature of addiction and the approaches designed to treat it. The nature of Recovery Management as a philosophy of organizing addiction treatment and recovery support services to enhance early prerecovery engagement, recovery initiation, long-term recovery maintenance, and the quality of personal/family life in long-term recovery is described. The shift to a model of sustained recovery management includes changes in treatment practices related to the timing of service initiation, service access and engagement, assessment and service planning, service menu, service relationship, locus of service delivery, assertive linkage to indigenous recovery support resources, and the duration of posttreatment monitoring and support.
Keywords
Addiction recovery managementAddiction as a chronic disorderTreatment careerRecovery
Introduction
The conceptualization of addiction as a chronic disorder has profound implications for the design, delivery, evaluation, and funding of addiction treatment. This chapter provides a framework for understanding the front-line service practices that accompany the shift from an acute care model of addiction treatment to a model of sustained recovery management.
Addiction as a Chronic Disorder
Alcohol and other drug (AOD) problems present in transient (developmental or situational) and prolonged patterns [1–4]. While the former are amenable to processes of natural recovery and brief, nonspecialized professional intervention, the latter consume inordinate quantities of specialty sector addiction treatment services [5]. Clinical populations (those admitted to addiction treatment) are distinguished from those in the larger community with AOD problems by greater personal vulnerability (e.g., family history of AOD problems, early age of onset of AOD use, traumatic victimization), greater problem severity and complexity (e.g., multiple drug dependence, injection drug use, and co-occurring psychiatric illness), and by lower levels of recovery capital (internal and external recovery initiation and maintenance assets) [5].
Studies of addiction and treatment careers [6, 7] reveal that prolonged years of AOD use and related problems and multiple treatment episodes can precede the achievement of sobriety and improvements in global health. The majority (64%) of persons entering addiction treatment in the USA already have one or more prior treatment episodes, including 22% with three or four prior admissions and 19% with five or more prior admissions [8]. Addiction treatment as a cultural institution promised that it could stop the “revolving door” through which those with AOD problems cycled through local jails and hospital emergency rooms. It is rapidly becoming the new revolving door. This is not to say that recovery from even the most severe AOD problems is not possible. The recovery prevalence rate for persons meeting lifetime criteria for a substance use disorder ranges between 50 and 60% [9–12], but the processes through which such recoveries are achieved are more complex and prolonged than once thought.
McLellan et al. [13] have confirmed that severe substance use disorders share numerous characteristics with type 2 diabetes mellitus, hypertension, asthma, and other chronic health disorders. Severe substance use disorders and other chronic health disorders
· Are influenced by genetic heritability and other personal, family, and environmental risk factors
· Can be identified and diagnosed using well-validated screening questionnaires and diagnostic checklists
· Are influenced by behaviors that begin as voluntary choices but evolve into deeply ingrained patterns of behavior that, in the case of addiction, are further exacerbated by neurobiological changes in the brain that weaken volitional control over these contributing behaviors
· Are marked by a pattern of onset that may be sudden or gradual
· Have a prolonged course that varies from person to person in intensity and pattern
· Are accompanied by risks of profound pathophysiology, disability, and premature death
· Have effective treatments, self-management protocols, peer support frameworks, and similar remission rates, but no known cures [14].
Characterizing addiction as a “chronic disorder” does not mean that (1) all AOD problems have a prolonged, progressive course, (2) all persons with AOD problems need specialized professional treatment and long-term posttreatment monitoring and support, (3) all persons suffering from substance dependence will relapse repeatedly and require multiple treatment episodes, (4) there is minimal hope for full, long-term recovery, or (5) that persons with a chronic form of substance dependence have any less personal responsibility for illness self-management than those with diabetes or hypertensive disease [14]. To avoid contributing to addiction-related professional and social stigma, communications about addiction as a chronic disorder are best accompanied by such disclaimers.
Characterizing addiction as a chronic disorder does suggest that much could be learned by studying how individuals, families, and health care professionals actively and effectively manage other chronic health conditions. Those patterns of severe AOD problems that constitute a chronic disorder should be afforded the basic supports used in the management of other chronic health conditions, including
· Mass public education, screening, and early intervention
· Continuity of contact over a sustained period of time with a primary health care management team
· Patient/family education and empowerment to self-manage the condition (including the mobilization of family resources to support recovery initiation and maintenance)
· Access to the latest advancements in medications for symptom suppression and management
· Access to peer-based recovery support groups and advocacy organizations
· Sustained monitoring (checkups), recovery coaching (to include focus on global health via diet, exercise, sleep, and coping strategies), and when needed, early reintervention.
Addiction has been characterized as a chronic disease in the USA for more than two centuries [15], but it has been professionally treated primarily within an acute care framework. If the field of addiction treatment really believed addiction was a chronic disorder, it would not, for example,
· View prior treatment as a predictor of poor prognosis (and grounds for denial of treatment admission)
· Convey the expectation that all clients should achieve complete and enduring sobriety following a single, brief episode of treatment
· Punitively discharge clients for confirming their diagnosis (becoming symptomatic via AOD use during their treatment)
· Relegate posttreatment continuing care services to an afterthought
· Terminate the service relationship following brief intervention
· Treat serious and persistent AOD problems in serial episodes of self-contained, unlinked interventions.
The emergence of a chronic disease framework to conceptualize addiction and recovery processes opens new ways to understand the treatment process. This new view contains three critical assumptions. First, a single brief episode of professionally directed treatment in the absence of posttreatment monitoring and support rarely has the potency to generate sustainable recovery for those with the most severe and complex substance use disorders (i.e., substance dependence with co-occurring medical/psychiatric illness). This view suggests that we as a culture are placing individuals in treatment modalities of low intensity/extensity whose design offers little likelihood of sustained remission and recovery and then personally blaming the client when that success fails to materialize. Second, multiple episodes of treatment, when integrated within a long-term recovery management plan, can generate cumulative effects and constitute incremental steps in the developmental process of recovery. Third, particular combinations and sequences of professional treatment interventions and peer-based recovery support services may generate synergistic effects (dramatically elevated long-term recovery outcomes).
Recovery as a Time-Sustained Process
A growing body of scientific studies suggests that addiction recovery is a stage-dependent process [16–23]. Stage theories of addiction recovery share six core ideas.
1.
2.
3.
4.
5.
6.
The idea that recovery is a time-dependent process draws empirical support from studies of the durability of addiction recovery (the point at which the future risk of lifetime relapse drops below 15%). Such studies have concluded that recovery stability is achieved not in the days and months following recovery initiation but at a point years into recovery – 4–5 years for recovery from alcohol dependence and even later for recovery from heroin addiction [10, 24–28].
Viewed over a life cycle perspective, long-term addiction recovery involves a process of recovery priming (destabilization of addiction and early motivational enhancement for recovery), one or more experiments in recovery initiation and stabilization, the transition from recovery initiation to successful recovery maintenance, and enhancement of quality of life in long-term personal and family recovery. Current models of addiction treatment focus only on the second of these four stages. We will briefly explore how approaches to long-term recovery management address all of these stages through critical changes in treatment practices.
Evolution of the Acute Care Model of Addiction Treatment
The acute care (AC) model of addiction treatment is distinguished by the following characteristics:
· Services are delivered “programmatically” 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).
· The intervention is focused on symptom elimination for a single primary problem.
· Professional experts direct and dominate the assessment, treatment planning, and service delivery decision making.
· Services transpire over a short (and historically ever-shorter) period of time – usually as a function of a prearranged, time-limited insurance payment that is designed specifically for addiction disorders and “carved out” from general medical insurance.
· The individual/family/community is given the impression at discharge (“graduation”) that “cure has occurred”; long-term recovery is viewed as personally self-sustainable without ongoing professional assistance.
· The intervention is evaluated at a short-term, single point-in-time follow-up that compares pretreatment status with discharge status and posttreatment status months or at best, a few years, following professional intervention.
· Posttreatment relapse and readmissions are viewed as the failure (noncompliance) of the individual rather than as potential flaws in the design or execution of the treatment protocol [14].
This acute care model was shaped by the medicalization, professionalization, and commercialization of addiction treatment and a system of managed behavioral health care that forced treatment into discrete, ever-briefer episodes of care. Even modalities that involved sustained contact with those being treated (e.g., therapeutic communities and methadone maintenance) were profoundly influenced by this acute care model of intervention [5].
Recovery Management: Long-Term Recovery as an Organizing Image
A confluence of interests in the past decade sparked calls to reexamine addiction treatment as a system of care and to extend the acute care model of intervention into severe AOD problems to a model of sustained recovery management. Recovery management (RM) is a philosophy of organizing addiction treatment and recovery support services to enhance early prerecovery engagement, recovery initiation, long-term recovery maintenance, and the quality of personal/family life in long-term recovery [5]. There were concurrent calls to wrap this philosophy of recovery management within recovery-oriented systems of care (ROSC) – the creation of a larger cultural and policy climate within which long-term addiction recovery could flourish in local communities.
These systems transformation efforts unfolded at national, state, and local levels (see chapters in Part III of this volume) and were accompanied by efforts to define recovery [29], calls for a recovery-focused research agenda [30], and growing interest in peer-based recovery support services and new recovery support institutions (recovery community centers, recovery homes, recovery schools, recovery industries, and recovery ministries) [31, 32].
The emergence of RM and ROSC as organizing frameworks reflected a broader conceptual shift in the addictions field from a traditional focus on pathology and intervention to a focus on long-term personal and family recovery [33–35]. The rapid rise of a new recovery-focused rhetoric within the addictions field led some treatment providers to question the necessity of change as they were already recovery oriented [36] and led recovery advocates to question whether this recovery rhetoric reflected anything substantially new or was simply the application of a new cosmetic to beautify a failing service system [37].
Changes in Service Practices
Efforts to define and evaluate recovery management as an organizing framework for addiction treatment involve key treatment system performance arenas. We discuss below eight such performance arenas (1) attraction/access to treatment, (2) assessment and level of care placement, (3) composition of the service team, (4) service relationships/roles, (5) service dose, scope, and duration, (6) locus of service delivery, (7) linkage to communities of recovery, and (8) posttreatment monitoring, support, and early reintervention. For each arena, we note the current prevailing practice and how service practices within that arena would change within a recovery management model. This comparison is based on available system performance data and the authors’ involvement with recovery management (RM) initiatives across the USA.
Attraction/Access to Treatment
The AC model of addiction treatment is not able to voluntarily attract and engage the majority of individuals experiencing substance use disorders. Only 10.8% of US citizens meeting DSM-IV criteria for substance abuse or substance dependence receive specialized addiction treatment each year [38], and only 25% will receive an episode of such care in their lifetime [39]. The vast majority of people currently entering addiction treatment do so under external coercion and at late stages of problem development. Attraction is compromised by problem perception (as not that bad), perception of self (I can resolve this on my own), perception of treatment (as inaccessible, unaffordable, and ineffective), and fear of perception of others (social stigma).
Treatment access and initial engagement are also of concern. There is a 50–64% dropout rate between the call for help and the first appointment at addiction treatment agencies [40]. Access to treatment for those seeking services is plagued by ambivalence about future drug use/abstinence, lack of geographically accessible treatment, waiting lists for treatment entry, personal/family/environmental obstacles to treatment participation, and high early dropout rates. Problems of treatment attraction and engagement are magnified for women, people of color, people with co-occurring disorders, and people with low-to-moderate severity of AOD problems [5].
A primary goal of RM is reaching people at early and middle stages of AOD problem development. This is achieved through public education and anti-stigma campaigns; assertive outreach programs; assertive waiting list management (interim support); lowered thresholds of engagement; use of case management to resolve obstacles to participation; and service delivery within nonstigmatized service sites. Early engagement is enhanced by “warm welcome” techniques, streamlined intake, telephone and mail prompts for service appointments, and extended clinic hours. Implementation of such strategies has been significantly enhanced by the work of the Network for the Improvement of Addiction Treatment (NIATx) [41]. RM’s assertive approach to identifying and engaging those in need of treatment services is based on a simple assumption: the earlier the timing of intervention for any chronic disease, the better the prognosis for long-term recovery and the lower the disease toll on the individual, family, and community [5].
Assessment and Level of Care Placement
AC and RM models of assessment differ significantly, as indicated in Table 5.1.
Table 5.1
Contrasting assessment procedures in AC and RM models of addiction treatment
|
Assessment dimension |
AC model |
RM model |
|
Primary unit of assessment |
Individual |
Individual, family, community |
|
Scope |
Categorical (addiction-focused) |
Global (comprehensive biopsychosocial) |
|
Focus |
Deficit-based (from problems list to treatment plan) |
Asset-based (focus on recovery capital – assets, strengths) |
|
Timing |
Point-in-time intake activity |
Continual |
|
Level of care placement |
Based primarily on problem severity and complexity |
Based on problem severity and complexity as well as personal, family, and community recovery capital |
|
Level of care decision making |
Responsibility of professional |
Greater participation by client and family |
The key dimensions of the assessment process within the RM model – continual, comprehensive, asset-based, family inclusive – are congruent with the principles that guide assessment of other chronic conditions, e.g., assessment must be global and continual, based on the evidence that chronic diseases have a tendency to beget other acute and chronic problems over time.
Composition of the Service Team
The prevailing AC model of addiction treatment has several anomalies related to its service workforce. First, the model is filled with medical rhetoric (patient, diagnosis, disease, treatment, prognosis, etc.), but most people admitted to addiction treatment in the USA spend little face-to-face time with physicians and other primary health care professionals during the course of addiction treatment, and patients’ primary care physicians have little, if any, role in that treatment. Second, there is growing awareness of the psychiatric, psychological, and social dimensions of addiction treatment and recovery, but psychiatrists, psychologists, and social workers are not routinely included in addiction treatment teams, even though the role of the addiction counselor has been clinically modeled on these roles. Third, the resurgence of recovery rhetoric in addiction treatment belies the plummeting recovery representation of addiction counselors, the loss or weakening of recovery-focused volunteer programs and alumni programs, and the weakened connections between treatment organizations and local mutual aid service committees [32]. Fourth, there is a growing body of evidence of the importance of posttreatment family and community support in long-term recovery [32], but family involvement and the involvement of indigenous community healers (tribal elders, clergy, sponsors) continue to be the exception rather than the rule in addiction treatment. Fifth, the excessively high turnover of the addiction treatment workforce [42] renders near impossible the achievement of the continuity of contact and support over time that characterizes the service relationships of health care providers who specialize in the management of chronic health conditions.
Several aspects of the RM philosophy seek to address these issues, including the involvement of primary care physicians in early screening, acute stabilization, and ongoing recovery checkups; the increased involvement of psychiatrists, psychologists, and social workers at key points in the long-term individual/family recovery process; the reengagement of recovering people via peer recovery support service roles; the revitalization of service work through alumni associations and volunteer programs; and the formal inclusion of indigenous healers within the treatment and recovery support team. RM advocates are also adamant that the future of RM as a philosophy of care hinges on stabilization and leadership development within the addiction treatment and peer recovery support workforce.
Service Relationships/Roles
The relationship between addiction treatment professionals and those they serve has historically been modeled on the psychotherapy relationship. Such relationships are hierarchical (expert-driven), fiduciary (one party taking responsibility for the care of the other), transient and short-term (a clearly defined beginning and end), and shaped primarily by external regulatory and payment authorities [15]. In contrast, the relationships between chronic disease specialists and their patients reflect a sustained “collaborative care” or “partnership” approach in which each patient is empowered to assume responsibility for the long-term management of his or her disorder with care team members serving as consultants to the patient and family in this process [43].
Within the RM philosophy, the role of “expert” who “treats” the client similarly gives way to a teaching, consultation, and support role focused on enhanced skills in illness self-management. The relationship becomes a long-term recovery support alliance [44] through which clients define, implement, evaluate, and refine their own recovery action plans [5, 8]. The rapid transition from professionally directed treatment plans to client-directed recovery plans is a distinct quality of the RM model [45]. The RM emphasis on “philosophy of choice” is based on the conclusion of studies that clients who are more active in their treatment rate their treatment experience (services, primary counselor, and treatment organization) more positively, remain in treatment longer, and achieve better posttreatment recovery outcomes [46–49].
Service Dose, Scope, and Duration
There is a dose effect of addiction treatment participation with recovery outcomes improving as dose increases [50–52]. The ideal minimum dose of treatment below which recovery outcomes deteriorate is 90 days of service for nonmethadone residential and outpatient programs (across levels of care) and 1 year for methadone maintenance [53–55]. The acute care model of addiction treatment is characterized by a low dose and duration of services and a limited scope of services incongruent with the needs of persons with high problem severity/complexity and low recovery capital [5]. The majority of persons entering addiction treatment in the USA consistently receive less than this optimal dose [5], and less than half of those admitted successfully complete treatment [8].
Within the RM perspective, these inadequate service doses are analogous to providing suboptimal dosages of antibiotics in the treatment of a bacterial infection; the dose may be sufficient to temporarily suppress symptoms but may contribute to the return of the illness in a more virulent and treatment-resistant form. The RM model seeks to extend the dose of recovery support by wrapping traditional treatment in a longer continuum of pretreatment and posttreatment recovery support services and expanding the menu of clinical and non-clinical recovery support adjuncts – a trend consistent with research that ancillary services can enhance recovery outcomes by 25–40% [56, 57].
Locus of Service Delivery
The acute care model of addiction treatment is based on a series of encounters between addiction professionals that occur within an institutional environment. The clinical action unfolds on the professional’s turf, not the client’s. RM, as a philosophy of care, draws on the recognition that the family and social environment can significantly enhance or rapidly erode the effects of these brief clinical encounters [58, 59]. It calls for understanding the ecology of long-term recovery by shifting the question of how to get someone literally and figuratively “into treatment” to the question, “How can a long-term recovery process be firmly nested within each person’s natural environment, or failing that, create alternative recovery-conducive living environments within the larger community?” The latter question opens the potential to “treat” families, neighborhoods, and communities as well as individuals. It also moves the focus of recovery support from a strictly intrapersonal endeavor to one of creating family and community milieus conducive to long-term addiction recovery.
At its most practical level, RM mobilizes resources within the family and community to support recovery through three processes:
1.
2.
3.
This broadened definition of the “client” and the emphasis on the role of community in recovery are particularly apt for treatment organizations working with clients deeply enmeshed in cultures of addiction [60].
Linkage to Communities of Recovery
Recovery mutual aid societies and other recovery support institutions (e.g., recovery community centers, recovery homes, and recovery schools) have experienced substantial membership growth, geographical dispersion, and philosophical diversification [61, 62]. Numerous studies have concluded that participation in recovery mutual aid societies can enhance long-term recovery outcomes for diverse populations [63–65], as can participation in other recovery community support institutions [66, 67]. These potentially salutary effects are offset by addiction professionals’ lack of knowledge of recovery mutual aid alternatives, passive (verbal encouragement only) linkage procedures, low rates of posttreatment participation, and high posttreatment dropout rates [32, 68].
Recovery management as a philosophy of addiction treatment emphasizes the importance of assertive linkage to communities of recovery. These assertive procedures include orientation to the value of recovery support group participation; an introduction to support group choices and the philosophy, language, and meeting rituals of various groups; encouragement to set a personal goal for group participation; use of a volunteer “guide” to facilitate entry into recovery support group networks and meetings; provision of transportation to meetings; and processing responses to meetings [69, 70]. Assertive linkage to recovery support groups early in addiction treatment increases posttreatment participation rates and recovery outcomes for adults [71–73] and adolescents [74]. The same assertive linkage procedures used for recovery support groups are also used to link people to other recovery support institutions. A core belief within RM-oriented programs is that there are multiple pathways and styles of long-term recovery and that all are cause for celebration. It is assumed that all frameworks for long-term recovery maintenance will have individuals who optimally respond, partially respond, and do not respond [75], and that client choice and individualized matching afford the best personal prospects for successful long-term recovery support [76].
Posttreatment Monitoring, Support, and Early Reintervention
Two themes emerge in long-term follow-up studies: treatment effects diminish over time, and relapse rates are high [77]. The majority (over 50%) of people completing specialized addiction treatment in the US resume AOD use in the year following treatment, most within 90 days of discharge from treatment [78–80]. The rate and speed of relapse is even higher for adolescents completing addiction treatment [81]. Put simply, most individuals are fragilely balanced between recovery and readdiction in the weeks, months, and early years following their discharge from addiction treatment [82]. Between 25 and 35% of all clients discharged from addiction treatment will be readmitted to treatment within 1 year, and nearly 50% will be readmitted within 2–5 years [51, 83, 84].
In the prevailing acute care model of addiction treatment, clients are discharged with referral to another level of care or encouraged to participate in “aftercare” groups and/or a recovery mutual aid group. “Stepped care” from higher to lower intensity of service contact through an integrated continuum of care and support is the aspirational ideal of the treatment system [85], but this goal is achieved for only a minority of clients. Only one in five adults in the USA receives a significant dose of continuing care [86], and only 36% of adolescents received any continuing care following discharge from residential or outpatient treatment [87].
There is a growing body of scientific evidence that suggests that posttreatment monitoring (recovery check-ups) and support can elevate recovery outcomes for adults [82, 88, 89] and adolescents [90–92]. Assertive approaches to continuing care are a hallmark of the RM model. Such assertive approaches
· Encompass all admitted clients/families, not just those who successfully “graduate”
· Place primary responsibility for posttreatment contact with the treatment institution, not the client
· Involve both scheduled and unscheduled contact
· Capitalize on temporal windows of vulnerability (saturation of check-ups and support in the first 90 days following treatment) and increase monitoring and support during periods of identified vulnerability
· Individualize (increase and decrease) the duration and intensity of check-ups and support based on each client’s degree of problem severity and the depth of his or her recovery capital
· Utilize assertive linkage rather than passive referral to communities of recovery
· Incorporate multiple media for sustained recovery support, e.g., face-to-face contact, telephone support, and mailed and emailed communications
· Emphasize support contacts with clients in their natural environments
· May be delivered either by counselors, recovery coaches, or trained volunteer recovery support specialists
· Emphasize continuity of contact and service (rapport building and rapport maintenance) in a primary recovery support relationship over time [76].
The eight areas of service practice reviewed in this chapter underscore the dramatic changes in service philosophy and service practice that are involved in a shift from an AC to an RM model of addiction treatment and recovery support.
Summary
The addiction treatment field is shifting its conceptual center from pathology and interventions paradigms to a recovery paradigm. This shift is indicated by efforts to extend the acute care model of addiction treatment to a model of sustained recovery management comparable to approaches through which other chronic diseases are effectively managed.
Recovery management as a treatment philosophy is being embraced within larger systems transformation efforts aimed at creating ROSC. Recovery management involves substantial changes in treatment philosophies and practices and will by necessity involve significant changes in the policy and regulatory guidelines governing addiction treatment.
Key Points
The movement from an acute care to a recovery management model of addiction treatment involves:
· Community education, outreach, and expedited service access designed to identify and engage individuals and families at early stages of AOD problem development
· Assessment protocols that are comprehensive, strengths-based, family-focused, continual, and incorporate recovery capital into level of care placement decisions
· Expanding the recovery management team to include the patient, family, primary care physicians, recovery volunteers, and other culturally indigenous recovery support resources
· Shifting the service relationship from an expert–patient relationship to a sustained recovery management partnership via rapid transition from professionally-directed treatment plans to client-directed recovery plans
· A shift in emphasis from service intensity to service extensity and a broadening menu of clinical and non-clinical recovery support services
· A greater emphasis on home-based and neighborhood-based service delivery
· Assertive linkage to communities of recovery
· Posttreatment monitoring, stage-appropriate recovery coaching, and when needed, early reintervention.
Before exploring in Part III how these efforts are unfolding at state and local levels across the country, Part II will explore in greater depth the science upon which these systems transformation efforts are based.
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