Further Reflections on Acute Care Models of Addiction Treatment
I believe we live in the greatest era of snake oil salesmen in the history of mankind. —Michael Crichton, Next, 2006
The addictions treatment field has grossly oversold the effectiveness of a single episode of brief clinical intervention. For more than two decades, calls have increased for a radical redesign of addiction treatment and related recovery support services—a shift from acute care models of intervention to models of sustained recovery management (RM) nested within larger recovery-oriented systems of care (ROSC).
Defining Acute Care: Acute care (AC) models of addiction treatment encompass service interventions that intervene at a late stage of problem development via services focused on brief biopsychosocial stabilization that lack sustained support across the stages of long-term personal and family recovery. AC models of intervention that have dominated specialized addiction treatment since its inception in the mid-nineteenth century share distinct characteristics:
*Services are delivered “programmatically” in a uniform series of encapsulated activities (screen, admit, single point-in-time assessment, minimally individualized treatment, discharge, brief “aftercare” as an afterthought, termination of the service relationship).
*Clinical intervention is focused on symptom elimination for a single primary problem.
*Professional experts direct and dominate the assessment, treatment planning, and service delivery decision-making.
*Services transpire over a short (and historically ever-shorter) period of time—usually as a function of a prearranged, time-limited insurance payment designed specifically for addiction disorders and “carved out” from general medical insurance.
*The individual/family/community is given the impression at discharge (“graduation”) that “cure has occurred”: long-term recovery is viewed as personally self-sustainable without ongoing professional assistance.
*The intervention is evaluated at a short-term, single-point-in-time follow-up that compares pretreatment status with discharge status and short-point-in-time post-treatment status.
*Post-treatment symptom recurrence and needed readmission are viewed as failure of the client rather than flaws in the design or execution of the treatment protocol. Treatment in subsequent admissions is essentially the same as that of the first admission.
Why Acute Care? The modern addictions treatment field migrated toward an acute care model in the 1970s and early 1980s. The model reflected a bid for professional credibility of an emerging field, a needed response to the surge in public funding for addiction treatment, and a strategy to acquire private insurance reimbursement for such treatment. The resulting scheme of treatment and related funding policies resembled the acute care hospital, with duration of treatment becoming ever briefer following the advent of aggressive systems of managed behavioral healthcare. Detoxification programs were modeled on the hospital emergency room, inpatient and residential programs were modeled on acute care wards of the general hospital, and outpatient programs were modeled on the outpatient medical clinic. The resulting model prescribed a series of clinical steps all compressed in as little time as possible.
Potential Value of Acute Care: AC models of SUD intervention are very appropriate for people with low to moderate substance use disorders (SUDs) who also possess substantial recovery capital. Millions of people fitting this profile are today in long-term stable recovery who express unending gratitude for the AC treatment they received. For people with more severe SUDs, acute care is one critical stage in what needs to be a multi-staged process of sustained recovery support.
Unintended Consequences of AC Model: Failure to meet SUD severity criteria denies access to care for many people with mild to moderate substance-related problems and substantial recovery capital. People with the most severe, complex, and chronic SUDs are being repeatedly recycled through AC models of care whose low intensity and duration of services offer little hope of sustainable SUD recovery. (58% of people now admitted to addiction treatment in the U.S. have one or more prior treatment episodes, TEDS Data). I have regularly compared AC models of addiction treatment to providing inadequate dosages or duration of antibiotics in the treatment of bacterial infections. In both cases, treatment leads to temporary suppression of the symptoms but inadvertently leads to resurgence of the condition in a more intractable condition.
Cost-ineffectiveness of AC Model
Millions if not billions of dollars allocated to AC treatment is wasted due to the lack of earlier intervention into alcohol and other drug problems and the lack of long-term post-AC recovery support services. Service utilization and related profits within inpatient and residential treatment programs would plummet if improved recovery rates dramatically reduced multiple treatment admissions. Knowledge of that fact is a major obstacle to needed systems transformation within the addiction treatment industry. Ideally, dollars now allocated almost exclusively to AC treatment of addiction in the U.S. would be reapportioned across the stages of long-term personal and family recovery.
Ethics of Acute Care: Acute care models of addiction treatment that lack assertive outreach to shorten addiction careers and recovery support services across the stages of long-term recovery should be called out for what they are: clinical incompetence and financial exploitation, by consequence if not intent. The practice of recycling people with severe, complex and chronic SUDs repeatedly through AC-limited services is more money machine than “treatment “ and should be professionally and publicly exposed as such.
Alternative to AC Models of Care:
The alternative to the AC model that leaders in the addictions field are exploring is a model of recovery management nested within larger recovery-oriented systems of care.
Recovery management (RM) is a philosophical framework for organizing addiction treatment services to provide pre-recovery identification and engagement, recovery initiation and stabilization, long-term recovery maintenance, and quality-of-life enhancement for individuals and families affected by severe substance use disorders.
Recovery-oriented systems of care (ROSC) are networks of formal and informal services developed and mobilized to sustain long-term recovery for individuals and families impacted by severe substance use disorders. The system in ROSC is not a local, state, or federal treatment agency but a macro-level organization of a community, a state, or a nation. ROSC initiatives provide the physical, psychological, cultural, and social space within local communities in which personal and family recovery can flourish.
Distinctive Features of RM and ROSC
The emerging RM & ROSC vision calls for:
*strengthening the infrastructure of addiction treatment to ensure sustained continuity of support and accountability to the individuals, families, and communities served by addiction treatment institutions;
*more proactive systems of identifying, engaging, and ensuring service access for individuals and families at the earliest possible stage of AOD-related problem development;
*individual, family, and community needs-assessment protocols that are comprehensive, strengths-based, and ongoing;
*the utilization of multidisciplinary and multi-agency service models for supporting long-term recovery for those individuals, families, and neighborhoods experiencing severe, complex, and enduring AOD problems;
*the reconstruction of the service relationship from an expert model to a partnership model involving a long-term recovery support alliance;
*expanding the service menu, with an emphasis on evidence-based and recovery-linked service practices;
*ensuring each client and family an adequate dose and duration of pre-treatment, in-treatment, and post-treatment clinical and recovery support services;
*exerting a greater influence on the post-treatment recovery environment by shortening the physical and cultural distance between the treatment institution and the natural environments of those served, and by intervening directly to increase family and community recovery capital;
*assertive linkage of clients and families to recovery mutual aid groups and other indigenous recovery support institutions;
*post-treatment monitoring (recovery check-ups for up to five years following discharge from primary treatment), ongoing stage-appropriate recovery education, sustained recovery coaching, and, when needed, early re-intervention; and
*the systematic and system-wide collection and reporting of long-term post-treatment recovery outcomes for all individuals and families admitted to addiction treatment.
RM and ROSC system redesign would integrate the now isolated siloes of primary prevention, harm reduction, early intervention, treatment, and recovery support services.
People in personal/family recovery and a vanguard of addiction professionals are working diligently across the country to make this vision a reality. If I had another lifetime to devote to the elevation of the quality of addiction treatment in the United States, this is what I would be trying to achieve.
Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS) Discharges, 2015. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018. Accessed February 13, 2020 at https://wwwdasis.samhsa.gov/dasis2/teds_pubs/TEDS/Discharges/TED_D_2015/teds_d_2015_codebook.pdf
Kelly, J. & White, W. (Eds., 2010). Addiction recovery management: Theory, science and practice. New York: Springer Science
White, W. (2008). Recovery management and recovery-oriented systems of care: Scientific rationale and promising practices. Pittsburgh, PA: Northeast Addiction Technology Transfer Center, Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health & Mental Retardation Services