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We keep repeating episodic care, and we keep failing

February 12, 2016
by Roland Reeves, MD
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Attributed to Einstein is the oft-used quote defining insanity as doing the same thing over and over again and 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 when, years after tuberculosis was found to be caused by a bacteria, those suffering from the disease were still being confined to one of the thousands of “sanitoria” in the U.S. 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 alternatives are available, but we are not using them. A model applied to the treatment of professionals that has been available since the 1970s was shown by Robert DuPont, MD, in 2009 in the Journal of Substance Abuse Treatment to achieve a 78% five-year success rate, and of those who relapsed, only 15% had a second relapse. This is one of many reports that tout the success of professionals' treatment. Today’s usual methods, by contrast, lead to 50 to 90% of those completing treatment being readmitted within the first year after treatment.

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Moving away from an acute care model is long overdue. Telling patients that they have a chronic disease and then treating it with an acute care model has been confusing. The quality of care that we provide to our patients would be enhanced if we were to apply the three steps recommended by Dr. Reeves.
I would like to suggest that we go a little further. Let’s start using the language used by medical professionals treating other chronic diseases. Language is important. It influences how we think.
As far as I know, we’re still the only professionals using the word “aftercare.” It’s too easily translated into “afterthought.” I also don’t know what the “outcome” of a chronic disease is. Today I’m OK. I believe that people with hypertension are either “stable” or “unstable.” I don’t think that they “relapse.”
A lot of treatment centers have Alumni. “Alumni” implies graduates.
I love this movement. It’s really exciting.

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Thank you for posting an excellent and important article. I am in wholehearted agreement. As you may know, the highly successful DOT/SAP return-to-duty process can be construed as a long-term continuing care model that incorporates features of Contingency Management and includes an extensive reinforcement driven follow-up testing protocol. The following articles on this particular subject support your thesis:

Morrison, R. (2016). Protecting the workplace and saving lives. DATIA Focus 9(1), pp. 8-10.
2015.
Morrison, R. & DuPont, R. (2013). The new paradigm and the dot/sap process. Journal of Employee Assistance, 43 (1), pp. 26 – 28.

Best, Reed Morrison, Ph.D.,
CEO, American Substance Abuse Professionals (ASAP)

I agree that changes are necessary to move forward with any new treatments. Great article, very informative.

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Roland Reeves MD

Medical Director

Roland Reeves MD

@https://twitter.com/DestinRecovery

www.DestinRecovery.com

Dr. Roland Reeves, MD, is the Medical Director of Destin...