Addiction is increasingly understood to be a chronic disease. Until recently, the most common scenario in treating addiction was an “isolated acute episode” followed by one-time, short-term intervention. The broadening recognition of addiction’s chronic nature compels a fundamental change in treatment, a move away from acute episodic care and toward an environment that promotes ongoing management of the disease and sustains recovery. Some experts refer to this environment as “the recovery zone.”
| Chronic illnesses arise from an array of factors, including biological, psychological and social influences. “Many times, ‘lifestyle’ or personal behavioral choices are intimately involved in the onset and course of these disorders.” Severe substance dependence, like other primary chronic illnesses, is impacted by genetics and by “personal, family and environmental risk factors” … and is also “influenced by behaviors that begin as voluntary choices but evolve into deeply ingrained patterns of behavior.” Furthermore, prolonged drug or alcohol use compounds the problem by causing changes in the brain that diminish an individual’s capacity to control the “contributing behaviors1.”
William White and Thomas McLellan’s authoritative paper on addiction as a chronic disorder reviews the trade marks of acute treatment. Acute care, the authors note, is characterized by a fairly rigid course that takes place within a limited timeframe. The “programmatic” delivery of services includes screening, admission, a one-time assessment, treatment, discharge, brief period of aftercare, after which the relationship with the care provider comes to an end. The model features a central figure, a professional expert, who guides the entire process, from the assessment through the treatment plan and its delivery. Care occurs over a short period, in most cases determined by pre-arranged, time-restricted insurance payments. It is designed for addiction disorders and is separated from general medical insurance. At discharge, the patient and family receive the impression that a “cure” has occurred and that long-term recovery is self-sustained. Should relapse occur, blame is placed on the individual for non-compliance2.
The acute care model has succeeded with certain individuals, those with high “recovery capital.” This term refers to having stable housing, employment, and strong social networks. Taken as a whole, however, the current addiction treatment system, in which the lion’s share of resources is expended on acute care, has had low engagement rates and high attrition rates. Dropout rates between initial contact for an appointment at an addiction treatment agency and the first treatment session range from 50-64 percent. Nationally, more than half of clients admitted to addiction treatment do not successfully complete treatment; in New Jersey, just 52 percent of clients do so. These numbers reflect the fact that acute care does not work well for individuals with low recovery capital, meaning those who experience poverty, homelessness, unemployment, mental illness, or poor physical health - the very people public funds are meant to serve.
The Recovery Zone approach is in keeping with treatment of chronic illnesses, combining medical care with lifestyle factors to give the patient the best chance of sustained health. Under the Recovery Zone model, the treatment agency is just one of many resources brought to bear on the individual’s particular circumstances. Various supports need to work in concert with the client’s recovery plan. A key component that distinguishes this model from acute care is that motivation is often an outcome of the service process, not a precondition for entry into treatment. A strong therapeutic relationship can overcome low motivation for treatment and recovery4. Motivation for change can no longer be seen as the sole province of an individual, but as a shared responsibility with the treatment team, family and community institutions5.
When addiction is met with appropriate chronic care, one sees a higher success rate than with diabetes, a condition that also requires life-long disease management. A chronic course of treatment with addiction will produce a response rate comparable to hypertension and asthma. Chronic treatment benefits both consumers and society in that:
· It provides less expensive services to more individuals and decreases the unmet need for treatment;
· It provides prompt access to a full continuum of care that focuses on the client’s clinical needs and other contributing factors. Access to this care and adherence to evidenced-based practices consistently produce positive outcomes;
· It addresses a client’s individual recovery needs to facilitate entry and stabilization in the “recovery zone” as quickly as possible following an acute episode;
· It reduces service fragmenting, promotes service continuity, and increases the client’s capacity to manage his/her chronic health condition;
· It connects the client with a recovery coach to remove personal and environmental obstacles to recovery; links the client to the community; supports the recovering person as he or she develops; and implements, revises, and evaluates the recovery plan;
· It reduces the frequency of admissions to long-term residential, detoxification and short-term residential and increases in frequency admissions to outpatient levels of care;
· It reduces cost per client and increases retention rates.
The shift to a disease management model of sustained recovery supports will take time and it will require a tremendous effort to align concepts, contexts, policies, and service practices to support long-term recovery. The benefits will be apparent in both dollars and lives, as it will maximize resources in producing better outcomes for more people.
The adoption of a chronic care model for addiction has already been signaled at the federal level. As part of national health reform, new federal policies and funding are being linked to each state’s ability to provide treatment within a chronic care/recovery management model that responds to individuals who face issues of poverty, homelessness, unemployment, mental illness, and poor physical health. By embracing this model, New Jersey will be prepared to treat individuals over a continuum of care, creating the best opportunity for sustained recovery in which long periods of abstinence are shored up by gainful employment, stable housing, and supportive social and spiritual connectedness.
The Recovery Zone supports a person-centered and self-directed approach to care. It builds on personal responsibility, strengths, and resilience of individuals, families and communities to achieve health. This model will greatly advance addiction treatment whose core goals are long-term recovery and lifetime management of the disease. Download our Recovery Zone Brochure
1. McLellan, White, 2008
3. Gottheil, Sterling & Weinstein, 1997
4. Ilgen, et al, 2006
5. White, Boyle & Loveland, 2003