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

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

3. Past Models of Addiction
All based on acute
models of care

4. 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.

5. 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

6. 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.

7. 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)

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

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

15. 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)

16. 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)

17. 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);

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

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

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

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

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

23. 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)