The Revolving Door of Addiction Treatment

17757077 - vintage wooden revolving doorMarvin Ventrell, Executive Director of the National Association of Addiction Treatment Providers (NAATP), recently released the first quarter data from the NAATP Outcomes Pilot Program (OPP). It will be some time before the full results and implications of this study are complete, but there is one striking piece of data worthy of current reflection.  Of the 756 people who have been admitted to NAATP study sites to date, 63% reported having received prior treatment for a substance use disorder (SUD). NAATP membership includes a large portion of private addiction treatment organizations, but the NAATP data on prior treatment episodes of those admitted to addiction treatment is similar to previously reported national data.

The Substance Abuse and Mental Health Administration’s Treatment Episode Data Set for the years 2010-2012 reported that of the more than 5 million SUD admissions during those three years, only 37.4% had no prior admissions for addiction treatment, 33.5% had two or more prior admissions, and 11.7% had five or more prior admissions.  

In sum, more than 60% of people entering addiction treatment in the United States have one or more prior episodes of such treatment. What are we to make of such a finding? Modern addiction treatment was a social experiment begun, in part, to eliminate the revolving doors of local hospitals and jails through which addicted people repeatedly entered, exited, and reentered. Rather than eliminate this revolving door, we simply moved the door to a new social institution. 

In an earlier blog, I suggested that:  

 “We are routinely placing individuals with high problem severity, complexity, and chronicity in treatment modalities whose low intensity and short duration offer little realistic hope for successful post-treatment recovery maintenance. By using terms like “graduation” and ending the service relationship following such brief clinical interventions, we convey at “discharge” to patients, to families, and to all other interested parties that recovery is now self-sustainable without continued professional support. And this is true just often enough that this expectation is maintained for all those treated. For those with the most severe problems and the least recovery capital, this expectation is not a chance, but a set-up for failure—a systems failure masked as personal failure.”

Addiction professionals sometimes justify this practice of subjecting people to repeated episodes of acute biopsychosocial restabilization by noting the chronic nature of substance use disorders. But portraying severe and complex patterns of addiction as chronic disorders is a call to radically redesign addiction treatment and recovery support services. It is not a justification for repeated cycles of acute care that fail to achieve post-treatment recovery maintenance. Brief episodes of addiction treatment are highly appropriate for those with low to moderate problem severity and moderate to high recovery capital, but such interventions for those with the most severe substance use disorders are more likely to constitute brief respites within a prolonged addiction career than a catalyst for sustainable recovery. Portraying addiction as a “chronic disease” to justify multiple, time-extensive, and expensive treatment episodes constitutes, at best, inappropriate clinical care and, at worst, systematized financial exploitation.

If we as a field really truly believe that severe and complex SUDs are “chronic disorders,” the resources we invest in early screening and intervention and post-treatment recovery maintenance and support would be commensurate with the resources we now repeatedly invest to support recovery initiation/stabilization. There is growing interest in applying to addiction treatment what has been learned from primary medicine about the effective management of chronic disorders like diabetes, hypertension, asthma, and cancer. (In an earlier communication, I described such lessons drawn from my own cancer treatment.)

It is helpful to distinguish five stages of addiction recovery: precovery, recovery initiation and stabilization, recovery maintenance, enhanced quality of personal and family life in long-term recovery, and efforts to break intergenerational cycles of addiction. At present, nearly all recovery support resources are focused on recovery initiation and stabilization, and as a system of care we manage that stage more effectively and more safely than at any time in history. What we don’t achieve as a system is reaching people earlier in the development of addiction and supporting the transition from recovery initiation to long-term recovery maintenance and the subsequent stages of recovery.

There is growing interest in the clinical implications of conceptualizing addiction as a chronic disorder and repeated calls for expanding addiction treatment beyond models of acute care (AC) toward models of sustained recovery management (RM) nested within larger recovery-oriented systems of care (ROSC). But the clock is ticking. The cultural and therapeutic pessimism rising from the revolving door of addiction treatment must end. Treatment leaders must embrace RM/ROSC models of care for those with the most severe and complex substance use disorders and reserve AC interventions for those with mild to moderate problem severity and moderate to high recovery capital. Affected individuals and families and their advocates must demand individualized approaches to care that reflect distinctions in problem severity and recovery capital. Planners and payors of care must re-evaluate funding acute care interventions for the most severe substance use disorders when such care lacks assertive and sustained post-stabilization recovery support services. In the meantime, the revolving door continues to spin.