Now is the right time to upgrade the nation’s dysfunctional way of treating substance use disorders. This urgency is driven by three factors:
- The epidemic of prescription drug abuse, which is producing a new heroin crisis;
- The unfolding consequences of marijuana legalization; and
- The implementation of the Affordable Care Act and the Parity Act, which are dramatically increasing access to addiction treatment.
The demand for accountability in outcomes means we that cannot maintain the status quo.
Today more than 50% of patients relapse within 6 to 9 months following treatment completion. The near-universal use of detoxification and relatively brief episodes of treatment do not match the lifetime risk of relapse that characterizes addiction. Compounding this mismatch, most addiction treatment occurs outside of the rest of the healthcare system and outside of best practice standards. This segregated, stigmatized, acute care, poorly insured addiction treatment system is not working. Few addicted individuals perceive the need for treatment, even fewer enter treatment, and many do not complete treatment. Relapse after treatment is the most common outcome of treatment.
Improving treatment outcomes begins with recognizing that substantially improved outcomes are possible and that they can be expected. An achievable goal of treatment is recovery: the voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship. This means no use of alcohol or non-prescribed drugs.
Sustained recovery is the dominant outcome from the system of care management now used to treat addicted physicians, commercial pilots, and lawyers. They are evaluated, treated relatively briefly, and then monitored with care management for periods of 5 years or longer. Patients sign contracts requiring that they not use any alcohol or non-prescribed drugs; that they cooperate with close monitoring through the use of frequent, random drug and alcohol testing; and that any relapse to substance use and any other non-compliance will result in immediate and serious consequences—usually intensified care and monitoring. They are required to be active in community-based recovery support groups, typically Alcoholics Anonymous and Narcotics Anonymous.
This system works. Five-year findings reported in the peer-reviewed literature found that more than 75% of these professionals are licensed and productively working in their professions; 78% of participants never have a positive drug or alcohol test; and only 28% of those who do relapse to substance use have a second relapse during the five year period (1-2) (DuPont, McLellan, White, Merlo, & Gold, 2009; McLellan, Skipper, Campbell, & DuPont, 2008).
Because these outcomes are from professionals who stand to lose their licenses for non-compliance, this experience is often dismissed as irrelevant. But experience in treating similar populations of educated, well-supported patients with traditional acute care, symptom reduction approaches quite reliably results in rates of 40–60% relapse within 1 year of discharge. In contrast, continuing, recovery-oriented care management with monitoring and consequences has been employed within the criminal justice system (e.g., HOPE Probation and drug courts). Programs using similar random testing with swift and certain consequences produce low rates of relapse and enduring, positive outcomes—even among poorly educated criminal offenders with serious substance use problems. It is the recovery-focused system—not the patient population—that is responsible for these higher quality outcomes.
This model for the management of substance use disorders is called the New Paradigm (3) (Institute for Behavior and Health Recovery Management Working Group, 2013). The New Paradigm begins with entry into treatment, it then retains patients in treatment through completion, and extends the benefits long after discharge from treatment through extended monitoring with support plus swift, certain, and serious consequences for any noncompliance. This system of care management holds the promise of making recovery, not relapse, the expected outcome.
Why should excellent treatment outcomes from any disease or condition with such devastating health consequences be reserved for a tiny minority of patients? Presently, physicians who are intravenous opiate addicts are almost always treated through this system of care management without methadone or buprenorphine. They reliably achieve outstanding 5-year recovery outcomes. To protect the public, physicians need to return to work drug-free. Almost all other intravenous opiate addicts are treated through detoxification without continuing care management or placed on drug maintenance with relatively little hope of becoming and staying drug-free for 5 years or longer.
Recovery from addiction has been demonstrated to be reliably attainable, including for intravenous opiate addicts. It is time to make recovery the expected outcome for all who enter treatment. Providers and insurers can use specific measures to document the achievement of long-term recovery and of the steps needed to attain it. A shift in consumer awareness and demand for the achievement of sustained recovery, accompanied by provider and insurer mandates for recovery-oriented care, will encourage treatment programs to compete in achieving this goal, making recovery, not relapse, the expected outcome of addiction treatment.
Robert L. DuPont, MD, is the President of the Institute for Behavior and Health, Inc., in Rockville, MD.
Mark S. Gold, MD, is the Dizney Eminent Scholar at the University of Florida College of Medicine McKnight Brain Institute in Gainesville, FL.
- Thomas McLellan, PhD, is the Executive Director at the Treatment Research Institute in Philadelphia, PA.
References
DuPont, R. L., McLellan, A.T., White, W.L., Merlo, L., &Gold, M. S. (2009). Setting the standard for recovery: Physicians health programs evaluation review. Journal of Substance Abuse Treatment, 36, 159–171.
Institute for Behavior and Health Recovery Management Working Group. (2013). The new paradigm for recovery: Making recovery—and not relapse—the expected outcome of addiction treatment. Rockville, MD: Institute for Behavior and Health, Inc. Retrieved from http://ibhinc.org/pdfs/NewParadigmforRecoveryReportMarch2014.pdf
McLellan, A. T., Skipper, G. E., Campbell, M. G., & DuPont, R. L. (2008). Five-year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ, 337, a2038.