Case management: A model for the treatment of a chronic disorder

I've been trying to champion the need for treating addiction as a chronic disorder, rather than treating acute episodes.

I have a private practice. There are occasions on which I'm the first person whom a new patient talks to about substance use issues. That's where case management begins. The role of a case manager is to ensure that a patient receives the best possible care at all stages of the recovery process. It is important to state at the outset that addiction is a chronic disorder.

Developing rapport with my new patient comes first. It’s important that I don’t make any assumptions about a substance use disorder or co-occurring conditions at the outset. That’s the purpose of a thorough assessment. However, for the purpose of this blog, we’re going to assume that the assessment did lead to a substance use disorder diagnosis and co-occurring conditions.

At some point in the process, a level-of-care recommendation will be made and communicated to the patient, and possibly to significant others. In an ideal world, the patient would immediately accept the recommendation. The reality is that it’s not that simple.

I may be assessing a person who is, at best, in the precontemplative stage of change. Showing up has been the only action toward addressing what other people seem to think is a problem. The action that I would need to take at that time is to begin a therapeutic alliance with my patient.

I could confront my patient. I could present valid arguments supporting the patient’s need for care. In most cases, the patient has already heard it all and has well-rehearsed answers.

Or, I could form an alliance. What does the patient want? It’s highly likely that the patient wants significant others off their back. “OK, let’s figure out how to get these people off your back.” You don’t have to be therapist of the year to help this person see that getting these people to stop complaining has to include not drinking/using (at least for a period of time). There’s a good chance that the person will not succeed. So, maybe we’ve reached a point where this person begins to think about giving recovery a shot. We’re solidly into the contemplative stage of change. We now have a therapeutic alliance.

It’s likely to take the case manager several sessions to get to this point. Next, the patient makes a commitment to treating a chronic disorder. This is where recovery begins. I didn't say “abstinence.” I said “recovery.” There's a difference.

None of us have difficulty perceiving addiction as a chronic disorder. But there is resistance to applying a chronic care model to treat it.

Let's say that my patient accepts that withdrawal management is needed. As a case manager I’m going to refer my patient to the best possible facility. My role is to ensure that the patient receives the best treatment services available.

Today, in most cases, a person goes directly to a treatment center that they’ve heard is good. The process starts with an assessment. The result is usually that the patient is recommended for a level of care available at that facility. All services from this point on are likely to be delivered at the same facility.

A case manager steers a patient to the best possible services available over the course of a lifetime. The point that I'm trying to make is that over the course of a lifetime the patient and family are going to need a number of services. Treatment will not end with withdrawal management or residential care. Family counseling may be needed, or the patient may need to address trauma issues. Medical issues are likely to pop up.

Too often we perceive that treatment for addiction ends when the objectives of residential care are met. We hear people say things like “When I was in treatment,” or “I’ve been to treatment four times,” or “Joey needs to go to treatment.” The word “treatment” is being used to refer to residential care.

Can we imagine a diabetic saying “When I was in treatment?” Of course not. That's because diabetes is treated as a chronic disorder. The same thing needs to evolve for addiction.

Elsewhere I have argued for “recovery checkups” over the course of a lifespan. A person with addiction who has recovery checkups remains in treatment, although at a very low-intensity level of care.

It would be a good idea that a person with addiction have a physician who is board certified in addiction medicine. I had surgery some time ago. An addiction specialist really helped me to get through the pain. Many people are not aware that there are physicians who are board certified in addiction medicine. The American Board of Addiction Medicine does exist, and the number of physicians being certified is growing rapidly.

A case manager is the person who can ensure that the best professionals will provide the services that are needed over the course of a lifespan.

This is a chronic, lifespan disorder. Over the course of a lifetime, case managers may change (people move, change jobs, etc.) But the next case manager will always be the best person to ensure the highest quality of care.

This blog reflects the thinking of a growing number of people. Sometimes it's easier to keep doing the things that we've been doing for a long time. Change is difficult. It's also very exciting.

The role of case management is particularly important because of what we now know about the process of change. There is a growing consensus that it takes about five years for a change in lifestyle to become part of who we are.

We've been trying to do it in 28 days.