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

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

Past Models of Addiction All based on acute models of care

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.

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

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.

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 Fifty percent of outpatients drop out of treatment within one month (Hubbard, Flynn, Craddock, & Fletcher, 2001). Forty percent of court-ordered patients do not complete treatment (Watkins, Pincus, Tanielian, & Lloyd, 2003). (Hubbard, Flynn, Craddock, & Fletcher, 2001); (Watkins, Pincus, Tanielian, & Lloyd, 2003)

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 About 60 percent of patients use alcohol and/or drugs within six months after discharge from treatment. About 45 percent apply for residential treatment within 12 months of discharge (Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989) (Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989)

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

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

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 Neurobiological changes in the case of addiction

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

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

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

Addiction/Chronic Illness Compliance Rate Relapse Rate Alcohol Opioid Cocaine Nicotine 30-50% 50% 40% 45% 70% Insulin Dependent Diabetes Medication Diet and Foot Care <50% Hypertension Diet <30% 50-60% Asthma 60-80% (O’ Brien and McLellan, 1996) (O'Brien & McLellan, 1996)

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

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);

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

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

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

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

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

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