A. Thomas McLellan, PhD
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THE CONCEPTUAL AND HISTORICAL BASIS FOR THE EXISTING ADDICTION TREATMENT SYSTEM
Over the past two decades, research evidence of significant genetic heritability and persistent brain changes associated with heavy use of many substances suggest that many addictions may be best considered acquired, chronic illnesses, similar in terms of onset, course, management, and outcome to many forms of hypertension, adult diabetes, and other traditional chronic illnesses. In turn, clinical research has now shown significant evidence that long-term treatments are far more effective than are traditional acute care forms of treatment in managing—but not curing—addictions.
Chronic illnesses by definition have no cure—but they can be managed. Thus, patients are expected to be retained and managed for long periods. The management of chronic illness starts in the primary care setting—before an illness actually begins. Cases that do not respond to these “first-line” treatments are typically referred to specialty care providers to stabilize and reduce the emergent disease symptoms, to educate the patient and family, and then to refer the patient back to the primary care team. At this stage of treatment, the goal is to maintain the gains and to prevent clinically damaging and costly relapses.
Outcome evaluation in the management of chronic illnesses—like the care itself—is an ongoing clinical process. Clinicians are expected to evaluate individual patients during regularly scheduled appointments. These evaluations measure symptom severity, patient function, and medication side effects. These measures serve the dual purposes of evaluating patient improvement and also providing clinical decision support for judgments on whether to change the nature of care. This is critical because without ongoing care, management, and evaluation, time-limited treatments are likely to result in relapse, reoccurrence of serious symptoms, and significant expense. These interlocking stages of chronic illness care are referred to as the “continuum of care,” and the team-based, long-term, proactive strategy for care management is called the “Chronic Care Model” first described by Wagner and Bodenheimer.
THE CHRONIC CARE MANAGEMENT MODEL AND THE AFFORDABLE CARE ACT
The ultimate goals of the Chronic Care Management (CCM) model are teaching the patient and his/her family to acquire the motivation, skills, and supports necessary for continued self-management of their chronic disease. The CCM is decidedly proactive, using a range of electronic mechanisms to stay in contact with patients and to provide anticipatory clinical care options to maximize disease control and to prevent relapses that can lead to emergency department visits, hospitalizations, and poor health outcomes. Thus, the CCM model uses a multidisciplinary primary care team instead of just a single physician. There is mounting evidence indicating that the CCM model is more effective than is standard clinical care, is effective in the treatment of behavioral health conditions such as depression and anxiety as well as physical illnesses, is more appreciated by patients and physicians, and does not appear to cost more than does more traditional clinic care.
While the concept of addiction as a chronic illness has been attractive in research, addictions have not been part of mainstream health care and physicians have never been trained—or reimbursed—to manage addictions like other chronic illnesses. This will change with full implementation of the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act. These two pieces of legislation require virtually all health plans to offer prevention, early intervention, and treatment for the full spectrum of “substance use disorders.” The implications are significant. Instead of denying treatment to all but the most severely affected and segregating that care and its financing, the new legislation requires expanded efforts within mainstream health care settings to prevent the onset of substance use disorders, to detect and reduce “medically harmful use” before it advances to the point of addiction, and to provide better access to a broader range of attractive addiction treatment services for those most severely affected.
Integrating the treatment of substance use disorders into mainstream health care as a chronic illness is necessary both for improving care for the 23 million adults suffering from “addiction,” but also because undiagnosed, unaddressed “medically harmful substance use” is far more prevalent in general medical settings and severely compromises the diagnosis and management of 15% to 45% of patients receiving treatments for many other illnesses in general care hospitals and outpatient clinics.
A SUGGESTED CCM MODEL FOR SUBSTANCE USE DISORDERS
It is thus reasonable to ask what an appropriately conceptualized and organized continuum of care for substance use disorders might look like and how patients might be managed using an adapted CCM model within the new provisions of the Affordable Care Act. To these ends, four linked clinical stages are suggested, each with a specific clinical purpose that is related to the overall goal: patient self-management, with maximum function and low likelihood of relapse.
First, and most important, the CCM model is NOT just for the management of “addiction” but rather the full spectrum of “substance use disorders.” Second, because these stages and their clinical goals are linked, many of treatment practices and elements (e.g., medications, counseling, family education) will have a role in more than one stage—but to address different problems. A third point is that there are as yet very few clear biologic or behavioral markers to guide clinical decision making in questions of transition among these stages. The final point is that the clinical stages are NOT synonymous with specific settings or modalities of care.
The Early Identification/Intervention Stage of Care
The main and most desirable goal from this stage of the care continuum is to identify and then motivate change among individuals whose substance use is too frequent or too serious for their medical health. Once identified, a linked goal is to use the power of the medical teaching moment as well as clinical techniques, such as motivational interviewing, to help patients accept that their substance use may be a problem and that they are capable of reducing their use. Initial screening and brief motivational interventions should conclude with an agreed-upon target for use frequency and amount and an identified plan by which the patient will reduce their use. It is critical that the patient is monitored at least weekly for the first month following the initial intervention and biweekly to monthly over the ensuing 3 to 4 months. The monitoring can occur through telephone or other social media contact methods to check the effectiveness of the patient’s efforts and to offer support and encouragement for those efforts.
Screening and brief interventions will generally NOT be effective in more severe cases of substance abuse or dependence. Thus, postscreening monitoring of patient alcohol and other substance use will be an essential part of clinical decision making in these cases. If monitoring reveals that the patient cannot reduce his or her use to levels that are no longer medically harmful, this will be an indication of a more serious problem. In these cases, an important secondary goal from this stage of care is to have those patients accept that they may have a more serious substance use problem and agree to a more intensive form of clinical care. In practice, achieving this level of patient acceptance generally involves repeated motivational interviewing sessions—always accompanied by monitoring.
In cases where monitoring reveals significant reductions in the quantity and frequency of substance use below the levels that may be medically or socially harmful, this may signal a transition to the patient management stage of care (see below). In cases where substance use does NOT reduce, this is an important indication that the use disorder may have advanced in severity. In this case, a full, standardized assessment of the patient’s substance use history and their use-related medical, personal, and social problems is warranted. That assessment should provide clinical guidance for negotiating a more intensive intervention such as a period of stabilization of physical and/or emotional symptoms. The best available guidance for these kinds of clinical decisions will likely come from the American Society of Addiction Medicine’s clinical guidelines. Regardless of specific placement decision, the goal is to help the patient regain control of their substance use—which may require some patients to abstain totally—and it will be important to negotiate frankly with the patient about available options and the behavioral goals from those options.
The Stabilization Stage of Care
Alcohol and other drugs of abuse often cause significant physical and emotional problems directly due to the development of tolerance and/or indirectly due to long periods of sleep deprivation, poor nutrition, and general lack of personal care that are often associated with heavy substance use. The purpose of the stabilization stage of treatment is not to produce cure or lasting sobriety—but rather to prepare the patient to do well in a subsequent clinical monitoring/management stage of care. Thus, motivating and ultimately engaging the stabilized patient into some form of continuing care involving monitoring and management (in a residential or outpatient specialty care setting or in a primary care setting) is an important clinical goal of this stage of treatment. On its own, stabilization is rarely effective in helping severely affected patients achieve lasting recovery. Thus, this stage of treatment is best considered preparation for continued rehabilitation.
Physiologic stabilization can be inferred from standard biologic and behavioral indicators (vital signs, sleep pattern, appetite, mood). There is great variability in the time required to achieve physical and emotional stabilization, which will vary based upon the nature, duration, and intensity of the substance(s) used and the general physical and emotional health of the affected patient. However, most patients make rather rapid and often dramatic improvements in the standard indicators within 3 to 7 days of medical care.
The only recommended transition from the stabilization stage is to some form of clinical monitoring/management, which may occur within the primary care setting or within an outpatient specialty care substance abuse treatment program. Again, the best source of clinical guidance available here will be the current American Society for Addiction Medicine Placement Criteria. Regardless of setting, the goal is to help the patient gain control of their substance use. Again, it is possible for less chronically or severely affected patients to achieve “control” through careful moderation of their use. For patients with more protracted and/or severe use problems, it is likely that abstinence may be the only way to attain and maintain control. It will be important to negotiate frankly with the patient and their family about their options for attaining and maintaining control. Regardless of the care setting selected, patients entering (or reentering) the clinical monitoring/management stage of care will likely require intensive individual, group, and/or family therapies, contingency contracting, and often medications.
The Clinical Monitoring/Management Stage of Care
Clinical monitoring and management is the most variable—in time, procedure, and patient eligibility—of all the stages of care. It is appropriate for patients who are physiologically and emotionally stabilized and who have gained initial behavioral control over their urges to use substances. Clinical goals here are to maintain the reductions in substance use, by providing care for the adjunctive health and social problems that were identified in the assessment, and to continue monitoring for relapse threats. In practice, this stage of care may last 3 to 9 months and can involve varying numbers and frequencies of medications, therapies, and social services (depending again upon the severity and complexity of the patient’s problems). One important resource within this stage of care is the availability of a living environment that is free from active substance abuse, as this is often an irresistible relapse factor. This type of living arrangement may be available within the family home, in drug-free housing, or in a residential specialty substance abuse treatment setting.
An additional and important goal from this stage of care is to educate and engage the patient’s family and social relationships to assist in the monitoring and support of the patient’s efforts to control their substance use. Several long-term studies of recovery from substance use disorders have identified ongoing support from family and social networks as key factors in the recovery, as well as the development of pro-social, healthy activities and behaviors that are inconsistent with substance use.
It is intuitive that patients with more severe, complex, and chronic substance use problems will likely require a greater number and frequency of clinical practices to achieve and sustain these clinical goals and will likely require a longer period of successful maintenance of these goals prior to transfer to a less intensive stage of care. However, even these intuitive assumptions have received very little research attention. There are important opportunities to study the specific behavioral indicators of high likelihood for successful transition to the personal management stage of care and the particular sets of clinical interventions that are most likely to produce patient changes that reach the designated performance threshold for transition.
Though important in all earlier stages of care, monitoring of substance use through biologic and self-report means is critical in the clinical monitoring/management stage for important clinical determinations such as whether to increase or decrease the intensity or change the composition of clinical practices provided to a patient and particularly whether to transition a patient to a more intensive or less intensive stage of care. Again, there has been little research regarding the appropriate behavioral and biologic criteria for these transitions. There are thus important opportunities for practical research in this area.
In general, self-disclosed or positive biologic tests for substances of abuse are an indication that there is need for more frequent monitoring (in person and/or through electronic media) and likely more intensive clinical interventions. The question of how long to continue any level of clinical monitoring/management in the face of continued positive biologic test results will always be an individual clinical determination. However, in general, it is wise to negotiate patient agreement on that level of continued use that will trigger treatment intensification in advance of care initiation.
A more welcome but no more informed question is when to refer a well-functioning patient with sustained reductions in substance use to the personal management stage of care. It is currently not known how long a period of sustained abstinence should be achieved before a stable, well-motivated patient can be expected to continue good function with little or no clinical management. Even when clinically managed and monitored patients are able to achieve stable periods of abstinence, the transition to personal management can be difficult and unsettling. Among the most reliable and robust findings from clinical studies of alcohol- and drug-addicted patients is that continued, active participation in Alcoholics Anonymous or other social support form of recovery maintenance is an excellent predictor of sustained sobriety and good social function. While this is quite clear in the case of severely addicted patients treated in specialty care programs, it is not known whether or to what extent it will hold true among less severely or chronically affected patients treated in primary care settings. Regardless, there is much to commend referral to AA or other social support group with instructions to get a sponsor, “share and chair” at meetings, and to attend 90 meetings in 90 days. There are now many controlled trials and field studies of AA participation showing that participation in posttreatment self-help groups is related to better outcome among cocaine- or alcohol-dependent individuals.
The Personal Management Stage
The term “personal management” is suggested to indicate the transition to care—management by the patient with little reliance on professional care, but likely with the informed assistance of family and friends. Historically, these kinds of informal care interventions were not included as part of the treatment continuum or as part of most treatment research studies. However, with the change in approach toward substance use disorders as a chronic illness, substantial research showing the value of participation in AA, and emerging research on the value of simply contacting, supporting, and monitoring the condition of previously treated patients, there has been increasing interest in fostering patient maintenance of health and function gains as a hedge against reinitiation of substance use problems and reutilization of expensive care options.
The personal management stage of care shares many of the goals of the clinical management stage of care—the essential difference is that in the latter stage, responsibility and capability for management rest on the patient and his or her family and social circle. In turn, it follows that one of the goals of the later phases of the clinical monitoring/management stage is to inform, train, engage, and practice the family and other social supports to take on these responsibilities in a practical and effective manner.
KEY POINTS
1. Because substance use disorders are similar to other chronic illnesses in etiology, course, and response to medications and therapies, the CCM model is an appropriate foundation for the management of substance use disorders, generally using the same methods, care teams, and organizational infrastructure now being designed for all other chronic illnesses.
2. Specifically, a four-stage adaptation of the CCM model was suggested: (1) early identification/intervention, (2) stabilization, (3) clinical monitoring/management, and (4) personal management.
ACKNOWLEDGMENTS
Research and writing of this paper were supported by grants from the National Institute on Drug Abuse, the Norlien Foundation, and the Betty Ford Institute.
REVIEW QUESTIONS
1. What is expected to be the most significant effect of the Affordable Care Act on the treatment of substance use disorders?
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