We keep repeating episodic care, and we keep failing

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.

The professionals model can be applied to non-professionals, as has been done successfully on a smaller scale in Connecticut and southeastern Pennsylvania. There are those who would say that these results cannot be obtained with “regular” people because the professionals have licenses to lose and are very educated. In my experience, these professionals are actually the most difficult to treat for these same reasons. The elements used as leverage for professionals in treatment, however, are no more powerful than a mother losing her children, a laborer losing his job and family, or any other number of tough consequences.

We can begin approaching the same level of success for everyone by applying three components included in professionals' programs that others do not normally receive:

1. Use the same entity or person that initiated treatment throughout the course of treatment. This provides a facilitator from detox through the initial acute care. Then, coordinated care is continued using recovery management principles that have been well-defined. This entity could be an interventionist or case manager. He/she would not only aid in keeping the patient engaged, but also would be instrumental in creating an environment with families and/or employers that maintains accountability, similar to that provided by professional licensing boards. This is the most important missing component right now, and in my opinion it is the reason why Richard Saitz, MD, and colleagues did not find improvements in their study of chronic care for addiction, published in JAMA in 2013.

2. Extend the time course of this oversight to five years. This time frame is a standard of care for other chronic diseases such as cancer, diabetes or heart disease, and it is the length of time of a typical professionals' program with proven success.

3. Objective accountability during this five-year period provided by random urine drug testing, and previously agreed-upon contracts with families or employers, stating specific consequences for failures.

Implementation of these components is not as difficult as discovering a revolutionary chemotherapy for cancer, or mobilizing world resources for treating a new strain of virus, yet failure to implement these components leads to just as devastating results. A total of 120 people will die today of this disease in the U.S., and many have been to treatment before.

A recent episode of “60 Minutes” addressed the heroin epidemic in suburbia. It is unfortunate that this is what it takes to get real attention. The segment brought several parents together to tell their stories. They are all from a central Ohio town and had recently lost loved ones to overdoses. Every single story included multiple episodes of attempted or failed treatments. Yet not once in the report was the question asked: “How come none of these treatments worked?” Parents were following what they were told to do by the treatment community, yet they lost their child. This is the unspoken but most telling portion of the story to me. We can do better, and we must.

I invite you to learn more about an independent coalition of treatment providers that have begun a grassroots effort to clean up industry practices and engage insurance payers for the implementation of this five-year chronic-care model.