Where`s the chronic-care approach to this chronic disease?

Most of us know someone with a chronic disease. I think of my friend who has type 1 diabetes. He’s doing OK now, but he has been hospitalized on two occasions in the 25 years I’ve known him. After being discharged from the hospital, he had numerous outpatient appointments with his endocrinologist. The appointments became less frequent as his blood sugar stabilized. To this day, he monitors 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.

My friend used to live in New York, and moved to Florida a few years ago. When he moved, he searched for and found another endocrinologist. He has regular checkups with his new physician. All seems to be going well. He has a good chance of maintaining wellness as long as his disease is monitored regularly.

The course of treatment described above is similar for all chronic diseases except for one: addiction.

I have a chronic addictive disease. However, the course of my treatment has been much different. In 1983 I was treated for 28 days , which was followed by 15 weekly group counseling sessions. I have not seen a physician since, nor has seeing a specialist of any kind been recommended to me. My disease was treated as an acute occurrence.

As long as treatment for addictive diseases is heavily loaded on the front end, using language and practices consistent with acute care, we will be talking about a chronic disease but treating acute occurrences.

To evolve toward a chronic-care model, we need to change how we think, what we say, and what we do.

Key changes

We can start by:

• Not giving patients the impression that they have completed treatment once they have completed the objectives of residential care. Patients do not “complete” treatment. Remaining abstinent from substance use while in a safe, secure environment is hardly completing treatment for a chronic disease. Yet, we have given that impression.

• Stopping “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 it is hardly complete. It is only the beginning of a lifetime of recovery, during which there will be many celebrations.

• Ceasing use of the term “alumni.” If patients do not graduate, there cannot be alumni. Changing the term to something like “friends in recovery” should not be difficult.

• Acknowledging that there is no such thing as “aftercare.” There is no “before care” either. There is just “care.”

• Dropping use of “primary care” as well. Let’s say that a patient begins recovery in an intensive outpatient program. Several weeks into treatment, the patient becomes unstable in his/her recovery. A referral is made to a residential level of care. The patient does so well in residential care that he/she is discharged to outpatient care. Which was primary?

• Dropping the word “outcome.” We measure progress along a continuum. When we measure the quality of a patient’s recovery 365 days after completing the objectives of residential care, we are measuring progress at a point in time.

• Dropping “relapse” as well. I can’t think of another chronic disease that uses “relapse.” Diabetic patients' blood sugar level is either “stable” or “unstable.” They haven’t relapsed. What constitutes stable or unstable recovery needs to be defined, but I doubt that it’s based solely on picking up one drink. I imagine that it has something to do with the consistent pursuit of abstinence.1

The language of acute care is the language of shame. Feelings of shame keep people away from treatment and recovery. Let's stop asking patients, “How many times have you been in treatment?” This is 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.

Also, we treat patients who need to be readmitted to residential care as though they have absolutely no experience with recovery. People began recovery when they were first diagnosed. That’s when they first start battling this chronic disease. It’s likely that coming back to a higher level of care was preceded by a period of not treating their chronic disease. Many patients go through a period during which they attempt moderate drinking. Those patients have learned that it doesn’t work. The beginner hasn’t learned that.

When we have patients who return to residential care do a first Step and tell their stories over and over, it shames them. It may not be Step 1 that they’re tripping over. The person coming back into care needs a full assessment.

Maybe we should stop asking patients to introduce themselves with, “My name is …, I’m an alcoholic.” A disease doesn’t define the entirety of a person. I’m also a teacher, a husband and a person in recovery. Maybe all I need to say is, “My name is Michael, I'm in recovery.”

Discharge planning

Discharge planning has not received the attention it deserves. A close friend remarked, “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.” There's being in treatment, and then there’s the rest of your life. Which is more important?

A discharge summary 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, and have any new issues come up in treatment? The plan needs to address medical, emotional, motivational, relapse, and recovery environment issues. The discharge summary needs to be the next provider’s starting point. It is also a legal document. It has to make sense.

The next provider (next level of care) needs to be carefully determined. Often it is difficult to determine what the recommended level of care is based on. There is no better place to argue for the adoption of the six dimensional criteria used by the American Society of Addiction Medicine (ASAM).1 We need a consistent framework for us to communicate.

Also, discharge planners/case managers need to have the same level of training and skills as therapists.

Optimal treatment

What does treatment need 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.

Personally, I see my dermatologist every three months whether I feel like I need to or not. I have skin checkups (monitoring). There have been times when I developed basal cell skin cancers. The intensity of my treatment increased at those times (intensive outpatient). As my symptoms became less intense, appointments with the dermatologist became less frequent (outpatient). I have continued to undergo quarterly monitoring so that my symptoms do not progress to where I need to be hospitalized (residential/inpatient).

All chronic diseases require regular monitoring. It could be quarterly or even semi-annually. William White refers to regular monitoring as “recovery checkups.”2 He recommends them for at least the first five years of recovery. I think that they need to be for a lifetime. The important factor is that the person with a chronic addictive disease perceives himself/herself to be “in treatment.”

A recovery checkup would be done by an addiction specialist. This is a physician certified by the American Board of Addiction Medicine (ABAM) and/or a psychiatrist certified by the American Board of Psychiatry and Neurology (ABPN), and who has demonstrated by education, experience and examination the requisite knowledge and skills to provide prevention, screening, intervention, and treatment for substance use and addiction.3

It is possible for the checkup to be completed by a team consisting of an addiction specialist and a therapist. The addiction specialist would complete the medical dimensions (ASAM dimensions I and II), while the therapist would complete the behavioral/cognitive/emotional, motivational, relapse, and environmental dimensions (III, IV, V, VI). There are an estimated 3,500 to 4,000 board-certified addiction specialists in the U.S., and the number is growing.

It is important that every person in recovery have an addiction specialist on his/her medical team. Patients with chronic diseases are regularly referred to specialists. Why not patients with an addictive disease?

Conclusion

Anyone who is fortunate enough to have achieved long-term recovery will have experienced illnesses, prescribed medications, surgeries, anxiety, depression, pain, sleep disorders, losses, changes in recovery environment, etc. How do people get through all of that and remain drug-free? The answer is that very few people do. Recovery monitored by an addiction specialist could help many more people achieve long-term recovery.

If we treat addiction like we treat any other chronic disease, this all begins to make sense. Let’s call it “lifespan/medically monitored recovery.”

Let’s also rely heavily on technologies that are available to us now, and on those that will become available. Right now we have computers, Skype, smartphones, Soberlink, and others. New technologies will emerge that will make it easier to extend the continuity and quality of care. Let's do it!

Michael Weiner, PhD, CAP, has been a program director, director of education and research, and consultant for Behavioral Health of the Palm Beaches since 1999. He has taught at the University of North Carolina-Greensboro and the Rochester Institute of Technology. He is an Associate member of the American Society of Addiction Medicine (ASAM).

References

1. Mee-Lee D, Shulman GD, Fishman MJ, et al. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (3rd ed.). Carson City, Nev.: The Change Companies; 2013.

2. White W. Recovery Checkups. 2014. Available at www.williamwhitepapers.com/blog/?s=recovery+check-ups.

3. American Society of Addiction Medicine. What is an Addiction Specialist? 2015. Retrieved from www.asam.org.