If Addiction is a Chronic Disease, We Need a Chronic Care Model to Treat ItBHOPB
I have this friend of mine who has a chronic disease: type 1 diabetes. He’s doing OK now, but he’s been hospitalized on two occasions in the twenty-five years that I’ve known him. After being hospitalized, he had a lot of outpatient appointments with his endocrinologist. He had frequent check-ups. While the frequency of the appointments seems to have slowed down, he still checks his blood sugar daily. My friend knows that he has to follow a daily plan to treat his disease. If he doesn’t, he could wind up in a hospital again or have to see his endocrinologist more often. In fact, this has happened on a few occasions since I’ve known him.
My friend used to live in New York. He moved to Florida a few years ago. When he moved to Florida, he searched for and found another endocrinologist. He has regular check-ups with his new physician. All seems to be going well.
My wife suffers from a different chronic disease: hypertension. Her treatment routine is very similar to that of my friend with diabetes. She has frequent check-ups. She was hospitalized on one occasion. After we moved she found another physician to monitor her hypertension. All is well today.
Historically, patients going through residential care are being told that they have a chronic disease, but the disease has been treated like an acute occurrence; this is in the process of changing.
I have a chronic addictive disease. However, the course of my treatment has been much different. I was treated for 28 days in 1983 which was followed by fifteen weekly group counseling sessions. I haven’t seen a physician since nor has seeing a specialist of any kind been recommended.
When a person leaves the hospital after developing chronic heart disease, they have an appointment scheduled to see a cardiologist. That person will have a cardiologist on their medical team forever. How come I don’t have an addictionologist?
I know someone who had their appendix removed some time ago. His appendix was diseased, it was removed. It was over. This person has not seen an appendix specialist since nor has he had any further difficulties. It was an acute occurrence and was treated as such. It seems that addictive diseases have been treated more like an appendectomy, an acute occurrence, than like chronic diseases such as diabetes or hypertension.
We Need to Change How we Think, How we Talk and What we Do:
Patients Do Not “Complete” Treatment
It’s up to us to stop giving patients the impression that they’ve “completed” treatment after they’ve met the objectives of inpatient or residential care. Remaining abstinent from substance use while in a safe, secure environment is hardly completing treatment for a chronic disease. Yet, we’ve given that impression.
We’ve Had “Coin-Out” Ceremonies or “Graduations”
Perhaps something like a “commitment to recovery” celebration would work better. It would recognize that hard work has been done, but that their work is hardly complete. It’s only the beginning of a lifetime of recovery during which there will be many celebrations.
Let’s Stop Asking Patients: “How many times have you been in treatment?”
It’s like asking them: “How many acute episodes have you had?” It also conveys: “How many times have you failed?” No one has ever asked my diabetic friend: “How many times have you been in treatment?” No one asks because diabetes is recognized as a chronic disease. My friend wouldn’t even understand the question.
We Still Treat Patients Who Need a Higher Level of Care Like they Have No Experience with Recovery
People enter recovery when first diagnosed. It’s likely that coming back to a higher level of care was preceded by a period of not treating their chronic disease, but even that was an experience that a first-time patient is lacking. We tell patients that doing the same thing over and over and expecting different results is a good definition of insanity. Why do we do the same thing? It demeans us as professionals.
Discharge Planning Has Not Received the Attention It Deserves
A close friend remarked that “The single most important thing that we do in treatment (residential or inpatient) is discharge planning and we give it the least amount of attention.” Maybe it’s not the “least amount of attention,” but it isn’t given the attention it deserves.
There’s being in treatment, and then there’s the rest of your life. Which is more important?
A discharge plan is essentially an assessment of the patient’s performance in treatment: which treatment objectives were met, which ones were deferred, which ones need more work, which new issues, if any, have come up in treatment? The plan needs to address medical, emotional, motivational, relapse and recovery environment issues. The discharge plan needs to be the next provider’s starting point. It is also the document that gives the next professional their first impression of the treatment provider. First impressions are hard to change.
It is also a legal document. It has to make sense.
The next provider (next level of care) needs to be carefully determined. Continued care recommendations vary. For the most part, they are individualized, but it’s hard to tell what criteria were used for the patient’s next placement. Actually, little clinical information is provided. In particular, there is very little discussed about a patient’s motivational level or recovery environment.
Discharge planners/case managers need more training and more involvement with the clinical team. There is a need for a discharge summary that looks more like an assessment.
What Treatment Needs to Look Like
It’s actually quite simple: it needs to look like how we treat any other chronic disease. The intensity of care should always match the severity of symptoms. When I say that people in recovery need to be in treatment “forever” I clearly do not mean a continuously high level of care.
Personally, I see my dermatologist every three months, whether I feel like I need to or not. I have skin check-ups. There have been times when I developed a basil cell skin cancer. The intensity of treatment increased. As I got better the frequency of my check-ups came down.
What about “recovery check-ups?” (White, 2014) How about at least semi-annual addiction check-ups?
Who would do them? How about an Addictionologist? What’s that? It’s a physician who has been certified by the American Board of Addiction Medicine (ABAM). Before actually sitting for the exam offered by ABAM, the physician would have completed a residency in Addiction Medicine. There are approximately 3000 board certified Addictionologists in the U.S. The numbers are growing. If you are in recovery, find one! Let\’s call this “Medically Monitored Recovery.”
If we treat addiction like we treat any other chronic disease, this all begins to make sense. Anyone who is fortunate enough to have achieved long-term recovery will have experienced illnesses, prescribed medications, surgeries, anxiety, depression, pain, sleep disorders, loss, changes in recovery environment, etc. How do people get through all of that and remain drug free? The answer is that many don’t. Recovery monitored by an ABAM/ASAM primary care physician could help many more people achieve long-term recovery.
The faster we change how we talk, what we think and what we do, the faster shame will disappear from the treatment of addictive diseases.