A quiet revolution is unfolding within the worlds of addiction treatment and recovery support.

This revolution is founded on new understandings of the nature of substance use disorders and their management.

It calls for shifting the treatment of severe and persistent alcohol and other drug (AOD) problems from an emergency room model of acute care (AC) to a model of sustained recovery management (RM).

The RM model wraps traditional interventions in a continuum of recovery support services spanning the pre-recovery (recovery priming), recovery initiation and stabilization, and recovery maintenance stages of problem resolution.

Particularly distinctive is the model’s emphasis on post-treatment monitoring and support; long-term, stage-appropriate recovery education; peer-based recovery coaching; assertive linkage to communities of recovery; and, when needed, early re-intervention. 

There are several forces pushing the addiction field toward a redesign of its treatment processes.

Frontline addiction professionals are articulating (and a growing number of scientific studies are confirming) the limitations of addiction treatment as currently practiced.

Grassroots recovery advocacy organizations are calling upon the treatment industry to reconnect professional treatment to the larger and more sustained process of addiction recovery.

Pioneer states (e.g., Connecticut) are building research, clinical, and recovery advocacy coalitions to infuse the recovery management model into new “recovery-oriented systems of care.”

And finally, technological advances in the management of primary chronic health care problems (e.g., diabetes, heart disease, asthma, arthritis, cancer, chronic lung disease, glaucoma, irritable bowel syndrome) are suggesting alternative approaches through which severe and complex behavioral health disorders might be managed more effectively.

PREMISES

The shift from acute care to sustained recovery management models rests upon six propositions.

1. Alcohol and other drug problems present in transient and chronic forms. The transient forms vary in intensity, from the clinical (substance abuse and substance dependence) to the subclinical (problems not meeting DSM-IV criteria for abuse or dependence).

Transient forms share a short duration (a single episode or period of problematic use) and a propensity for natural resolution or resolution through brief professional intervention.

Transient AOD problems are common in community populations, but are more rarely represented among populations entering addiction treatment.

Compared to community populations, clients entering addiction treatment are distinguished by: – greater personal vulnerability (e.g., family history of substance use disorders, early age of onset of AOD use, developmental trauma) – greater severity and intensity of use and related consequences – high concurrence of medical/psychiatric illnesses – greater personal and environmental obstacles to recovery – less “recovery capital” (the internal and external resources required to initiate and sustain recovery)

2. The evidence is overwhelming that the course of severe substance use disorders and their successful resolution (addiction, treatment, and recovery careers) can span years, if not decades. Alcohol and other drug dependencies resemble chronic disorders (e.g., type 2 diabetes mellitus, hypertension, and asthma) in their etiological complexity (interaction of genetic, biological, psychological, and physical/ social environmental factors), onset (gradual), course (prolonged waxing and waning of symptoms), treatment (management rather than cure), and clinical outcomes.

To characterize addiction as a chronic disorder is not to suggest that recovery is not a possibility. There are millions of people in stable, long-term recovery from addiction. The notion of addiction as a chronic disorder does, however, underscore the often-long course of such disorders and the sustained “treatment careers” that can precede stable recovery.

Recent studies have confirmed that the majority of people with severe and persistent substance use disorders (i.e., substance dependence) who achieve a year of stable recovery do so following 3-4 treatment episodes over a span of eight years.

3. Severe and persistent AOD problems have been collectively depicted as a “chronic, progressive disease” for more than 200 years, but their historical treatment more closely resembles interventions into acute health conditions (e.g., traumatic injuries, bacterial infections).

If we (the practitioners of addiction treatment) really believed addiction was a chronic disorder, we would not: – view prior treatment as predictor of poor prognosis (and grounds for denial of treatment admission) – convey the expectation that all clients should achieve complete and enduring sobriety following a single, brief episode of treatment – punitively discharge clients for becoming symptomatic – relegate post-treatment continuing care services to an afterthought – terminate the service relationship following brief intervention – treat serious and persistent AOD problems in serial episodes of self-contained, unlinked interventions

4. Acute models of treatment are not the best frameworks for treating severe and persistent AOD problems.

The limitations of the acute model of addiction treatment as currently practiced include:

– Failure to Attract: Less than 10% of U.S. citizens who meet DSM-IV criteria for substance abuse or dependence currently seek treatment, and most of those admitted to treatment arrive under coercive influences.

– Failure to Engage/Retain: More than half of the people admitted to addiction treatment in the U.S. do not successfully complete treatment, and 18% of people admitted to addiction treatment are administratively discharged from treatment.

– Inadequate Service Dose: A significant percentage of individuals completing treatment receive less than the optimum dose of treatment recommended by the National Institute on Drug Abuse.

– Lack of Continuing Care: Post-discharge continuing care can enhance recovery outcomes, but only one in five clients actually receives such care.

– Recovery Outcomes: The majority of people completing addiction treatment in the U.S. resume AOD use in the year following treatment, most within 90 days of discharge from treatment.

– Revolving Door: Of those admitted to publicly funded addiction treatment, 60% already have one or more prior treatment admissions, and 24% have three or more prior admissions. Between 25% and 35% of clients who complete addiction treatment will be re-admitted to treatment within one year, and 50% will be re-admitted within 2-5 years.

A large number of people are undergoing repeated episodes of brief interventions whose designs have little ability to fundamentally alter the trajectory of substance dependence and its related consequences.

This failure does not result from client foibles or the inadequate execution of clinical protocol by service professionals. It flows instead from a fundamental flaw in the design of the intervention - an acute-care model of treating addiction that is analogous to treating diabetes or asthma through a single, self-contained episode of inpatient stabilization.

In the AC model, brief symptom stabilization is misinterpreted as evidence of sustainable recovery. 5. Most people discharged from addiction treatment are precariously balanced between recovery and re-addiction in the weeks, months, and years following treatment.

Recent studies have confirmed the fluidity of post-treatment adjustment. One such study conducted quarterly monitoring interviews of 1,326 clients over three years following an index episode of addiction treatment.

Each client was categorized each quarter as 1) in the community using, 2) incarcerated, 3) in treatment, or 4) in the community not using. More than 80% of the clients changed status one or more times over the course of the three years.

Beyond the groups of clients who categorically succeed or do not succeed stands a larger body of clients who vacillate between periods of recovery and periods of re-addiction.

The precarious nature of early recovery is further confirmed by longer-term studies finding that stable recovery from alcoholism (the point at which the future risk of lifetime relapse drops below 15%) is not achieved until 4-5 years of continuous recovery, and that stable recovery from opiate addiction takes even longer.

Such findings beg for models of sustained post-treatment monitoring and support.

PROMISES AND PROSPECTS

Recovery management models hold great promise in treating severe and complex substance use disorders. Chronic disorders are disorders that resist cure via brief intervention but can often be successfully managed (the achievement of full or partial recovery).

Such management entails care and sustained support aimed at enhancing the strength, quality, and durability of remission periods and shortening the frequency, duration, and intensity of relapse episodes.

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Continued in longer pdf document: facesandvoicesofrecovery.org