A continuing-care mindset

The American Society of Addiction Medicine (ASAM) defines alcoholism as a chronic and progressive disease characterized by continuous or periodic impaired control over drinking, preoccupation with alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. We all know that patients can and do benefit greatly from treatment, but the rate of relapse is high. We deal with a disease that affects our patients for a lifetime. At Addiction Recovery Resources of New Orleans (ARRNO), we believe that treatment should acknowledge that reality, recognizing relapse as an indication for a revisit of the treatment plan, not discharge.

At ARRNO, we have left behind the cookie-cutter approach to the treatment of addiction. Our program is based on the disease of addiction as a chronic illness, similar to other chronic illnesses that require individualized care. We have established protocols to move patients through a continuum of levels of care and intensities of service to meet individual needs. Our philosophy is intentionally similar to that of any other chronic disease management model, such as one governing treatment for asthma or hypertension.

ARRNO began in 1992 as an effort of the Young Leadership Council, a philanthropic association in New Orleans. The program originally was based on a 90-day residential treatment model prominent at that time (Metro Atlanta Recovery Residences). An early board member had experience with that facility and gave rise to the idea of bringing this type of treatment to the New Orleans area.

Flexible services

Over time and with the evolution of medical treatment for addiction, the facility and its treatment programs have evolved as well. Length of stay in our residential program varies based on the individual's needs. Our intensive outpatient treatment program includes a residential component for those people whose appropriate level of care is outpatient but who do not have supportive living arrangements.

We can detoxify patients in either an ambulatory or residential setting. We can and frequently do address psychiatric comorbidity (such as bipolar disorder, unipolar depression, attention-deficit disorder, and personality disorders) with medication and with specialized behavioral and psychotherapeutic techniques.

Our IOP constitutes the usual referral for patients with “a house, a spouse, and a job,” or for those not previously in treatment. We conduct this program in the evening and encourage patients to continue in the workplace when detoxification issues resolve. A unique understanding is that couples should be in treatment together, as they usually have different but complimentary aspects of addictive disorder. There is no additional charge for the presence of the spouse. Sometimes in these arrangements individuals present to group alone or are separated from their significant other to work on sensitive issues, but rarely is this necessary. Patients who fail IOP by repeated relapse or who have had previous treatment and then relapsed are referred to our residential treatment program.

Residential treatment is set up with an initial education phase. This includes groups and lectures throughout the day, exercise and recreational participation, attention to activities of daily living in a community setting, and 12-Step attendance in the evening. Residents live four to six people in three-bedroom apartments segregated by gender. Men and women often live in adjacent apartments.

The interpersonal relational aspects of this community are seen as a key element of the treatment process, as is the cooperative engagement in household chores. Interaction among patients with unhealthy relationship skills is an important part of the community component of treatment and is often an opening into the need for change at depth. Often, opposite gender attraction issues emerge, and these are part of the community milieu therapy. (Of course, our “Cardinal Rules” prohibit sexual acting-out.)
There is a strong 12-Step orientation, with daily 12-Step attendance facilitated and required. Transportation is provided for a variety of 12-Step meetings, so that patients are exposed to groups with which they can identify.

Following completion of the education phase in residential treatment, patients transition to the application phase. The idea here is that vocational considerations are crucial to recovery. Patients are required to return to their current employment, find employment if they don't have a job, enter school, or, in the case of the occasional retired or disabled person, engage in volunteer work. A foundation belief is that good recovery requires participation in society and that participation in society promotes good recovery.

The various activities of the community continue during the application phase. A number of people return to their homes at this stage. Groups meet in the evening and address issues that are frequent components of relapse. The psychotherapy group is primarily interpersonal but borrows heavily from treatment programs for adult children of alcoholics and other types of dysfunctional families. The focus is on identifying and appropriately processing feelings and healing developmental trauma while learning skills of self-parenting. Originally we aimed to make this a two-month process, but over time the range of continued participation in the application phase has become one to 12 months.

Our continuing care is a lengthier process following IOP or completion of the application phase of residential treatment, and is unique in that there is an out-of-pocket expense involved ($20). Groups are kept small and focus on treatment plan goals and objectives. The therapists are master's-prepared and have ongoing professional relationships with their patients.

Because addiction is a disease, treatment at ARRNO is medically directed and supervised. All patients have direct medical evaluation and medical care. This sometimes occurs daily and sometimes, in the case of an intensive outpatient experience, only once in the treatment process. An addiction medicine specialist who is also board-certified in psychiatry and/or family practice directs a weekly multidisciplinary treatment team meeting (staffing).

Our space is a medical office building that shares a parking lot with the residential component: an apartment complex with a patio/garden and a small athletic activity area. The impression our setting conveys is one of competence without elitism. The interest is in providing treatment in a setting as close to real life as possible. The patients are a cross-section of middle class, working class and professional people who mingle well and find much in common in the course of treatment.

Case studies

Examples of recent experiences in our organization can help illustrate the approach we take. Recently, a financial professional was admitted to the IOP. He engaged in the program and seemed to do well throughout the intensive outpatient experience. In retrospect, it was noted by his counselors that he maintained a sense of elitism and, in fact, that receiving a DUI had prompted his treatment. He was compliant and completed the primary phase of intensive outpatient treatment but did not follow through with continuing care. His recollection was that he felt successful in his recovery and believed he would be able to discontinue his alcohol use. Although he participated in 12-Step activity required during primary treatment, he later tapered off his meeting attendance.

Unfortunately, in the ongoing conduct of his business he relapsed at a luncheon. His relapse progressed until he received a third DUI and was involved in unbecoming interactions with the police and finally was incarcerated. Through a process of cooperation with his counsel and the courts, his incarceration was shortened in favor of residential treatment at our center.

He originally had some difficulty with persistent elitism and a sense of entitlement; however, this resolved and he became a contributing member of the treatment community. Originally it was the avoidance of incarceration that maintained his treatment process, but in time treatment was effective and he was able to address the shame-based overachieving that drove him and drove his relapses.

Another example involves a young woman who, while working as a registered nurse in an emergency department, diverted opiates. She was seen for a five-day evaluation that identified substantial developmental trauma as well as a broad range of substance use over a significant period. As a result, a recommendation for residential treatment was made. During the treatment process, the extent of her developmental trauma was further realized, and concurrent individual therapy was recommended.

In the course of residential treatment she relapsed by ingesting the prescribed medication of another patient. This was identified and used as an opportunity to explore further the depth of her resistance to coping with her emotional pain. Although she clearly experienced a relapse in treatment, she was not discharged and the event was converted to a therapeutic experience.

The woman became financially unable to participate further in treatment at the recommended residential level, so money available in an endowment fund for the organization was provided for her as a non-interest bearing loan to allow her to continue. Over time, she left the ARRNO residence for independent living but continued to participate in the application phase as well as continuing her individual therapy and 12-Step recovery.

A third example is of a young man who was involved in a motor vehicle accident in his late teens and was prescribed opioids for pain. He developed a profound opioid addiction with ongoing participation in prescribed use as well as illegal purchases. He presented at age 30 after several unsuccessful abstinence-based treatment trials, including one with our IOP several years earlier. He was found to be in need of residential treatment and induced to buprenorphine in the first few days of treatment in the education phase. He was maintained on buprenorphine throughout the treatment experience, with the rest of his treatment indistinguishable from that of his peers.

As his thinking cleared he presented with symptoms of bipolar disorder and was diagnosed and prescribed medication. The medical regimen was successful and he remains in good active recovery on psychiatric medications and buprenorphine.

Our patients present with a variety of needs and a variety of levels of motivation. Sometimes we know that they would do better in treatment at a higher level of care, but the reality is they won't participate at that level and will at a lower level. We respect that choice.

Some patients relapse and some don't. This is true of all chronic diseases. We use relapse, when it occurs, as a vehicle for addressing the treatment plan. We have been able to create a spectrum of care within the same organizational umbrella, and have unbundled the components. Patients can be helped at various stages across that spectrum, for an individualized length of time that meets their needs and resources.

A. Kenison Roy, MD, FASAM, is Medical Director at Addiction Recovery Resources of New Orleans, a Metairie, Louisiana addiction treatment organization. He is also an Assistant Clinical Professor of Psychiatry at Tulane Medical School. His e-mail address is kenroymd@cox.net.