Substance Use Disorder Should Be Evaluated, Managed & Treated Like Other Chronic Health Conditions

Substance use disorder has been segregated from the rest of healthcare. As a result, it is treated very differently from other chronic conditions (e.g., hypertension).

Biological markers of disease status (e.g., urine tests) and measureable outcomes of quality of life are needed over a 5-year period to support long-term recovery for the most severe substance use disorders.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

The authors describe how the treatment of addiction to alcohol and other drugs has been conceptually, organizationally, and financially segregated from the rest of health care. For example, in other areas of chronic illness management there is consensus on when treatment is necessary, and when services will be paid for, which is almost always based upon one or more objective biological markers signifying disease status.

As treatment progresses, these markers are repeatedly monitored as part of the ongoing evaluation of the effectiveness of the care delivered, and used to inform modifications to care. The long-term continuity and monitoring often provided in primary care for other chronic diseases is missing in addiction. As a result, the approach to addiction treatment is quite different from other widespread chronic illnesses.

This editorial advocates for a consensus on how to measure and manage addiction services and for judging the effectiveness and value of addiction services based on the goal of five year recovery.

HOW WAS THIS STUDY CONDUCTED?

To empirically support their position on how to measure and manage addiction services and for judging the effectiveness of addiction services based on the goal of 5-year recovery, this editorial briefly described the efficacy of “chronic disease management” models. The models presented have consistently produced positive long-term outcomes for substance use disorders.

For example, the U.S. Physician Health Programs (PHPs) uses a state-based system of care management for addictions with the goal of producing the best long-term outcomes (e.g., recovery). The Physician Health Programs (PHP) tracks physician treatment and monitoring but does not provide the services directly. Physicians referred to the program are given random drug and alcohol testing. Missed drug tests are considered a serious violation and typically leads to the physician being taken out of practice for an extensive reevaluation. In addition, HOPE Probation and South Dakota’s 24/7 Sobriety Project offer comparable intensive monitoring procedures to support long-term recovery in criminal justice programs. Similarly, Caron Treatment Centers has implemented a program based on the care management of PHPs, called My First Year of Recovery.

WHAT DID THIS STUDY FIND?

This editorial was not designed to be a comprehensive review, but rather highlight examples of studies that implement long-term follow-ups:

One study of 16 Physician Health Programs showed that over five years of monitoring physicians, 78% of physicians remained substance free the entire time (e.g. never once tested positive for alcohol or other drugs).

Evidence from two criminal justice programs (HOPE Probation and South Dakota’s 24/7 Sobriety Project) with comparable intensive monitoring procedures, suggests similar rates of abstinence and improved quality of life can be achieved in addicted criminal offender populations.

Importantly, the authors note that abstinence is a means of supporting recovery and so abstinence objectives should be articulated to the patient, particularly those with severe substance use disorder.

WHY IS THIS STUDY IMPORTANT

The authors state that a fresh look at alcohol and other drug treatment evaluation using the standard of 5-year recovery is needed. Furthermore, objective markers should be used to measure the “disease state” as an indicator of treatment efficacy.

One key take away for primary care and health care systems is that consequences of continued alcohol and other drug use should not lead to punitive intervention but to new or intensified care, just as in the model used for promoting healthy behavior for other chronic disorders such as diabetes and coronary artery disease. Primary health care providers can manage the process using outside organizations that provide the specialty addiction care that may be required, followed by long-term continuing responsibility within the general healthcare (or primary care) setting.

As such, this five-year model will depend on the integration of shorter-term specialty substance use disorder (SUD) care with long-term SUD recovery management within primary/general care.

LIMITATIONS

The authors advocate for a new paradigm in the management of substance use disorders. Specifically, 5-year recovery for assessing the effectiveness of substance use disorder treatment. However, whereas care in PHPs is very well coordinated and outcomes measured as a result of participation in the program as a whole (i.e., random urinalysis screens, ongoing professional monitoring, specialty addiction treatment as needed), more work is need to articulate the processes by which the information on treatment efficacy will be exchanged between stakeholders in care systems without this degree of coordination and integration. The practicalities of how one organization (e.g., routine general healthcare) is responsible for the outcome data of multiple separate and possibly unaffiliated organizations (e.g., substance use disorder treatment providers) will need to be fleshed out. Conceivably, organizations that practice integrated care (e.g. primary care and substance use disorder treatment in the same setting) will struggle less with this task.

NEXT STEPS

More research is needed to establish if five-year monitoring and recovery management programs are associated with a reduced cost of addiction & related problems to society, although many studies already indicate investment in shorter-term addiction treatment is highly cost-effective.

Currently, the cost of susbtance use disorder (SUD) associated with tobacco, alcohol, & illicit drugs is devastating to the U.S., exacting more than $700 billion annually in costs related to crime, lost work productivity & health care.

If reduction in this financial burden can be shown through providing long-term care akin to the management of other chronic health conditions such as diabetes and hypertension, it would provide policy makers with the evidence they need to justify the allocation funds for such efforts and to inform constituents about the financial benefits of long-term monitoring using objective measures in routine healthcare settings.

BOTTOM LINE

For individuals & families seeking recovery: Understand that severe substance use disorders are comparable to other chronic conditions (e.g., diabetes) that require a long-term perspective on disease management. Punitive reactions to a relapse lack the focus on treatment modification (e.g., increase in care) that are needed to facilitate positive long-term outcomes.
For Scientists: Long-term models of recovery oriented care offer promise to improve patient outcomes. Cost-benefit analysis of short-term care vs. extended monitoring are needed to provide evidence of the reduced financial burden associated with severe alcohol and other drug addictions on society.
For Policy makers: Unlike other chronic diseases, five-year recovery models with objective measures of disease control and quality of life are missing from addiction treatment. Allocation of funds may help incentivize and enable healthcare practitioners (e.g., reimbursement) to follow-up with long-term recovery by using objective measures and defer to treatment specialist when increased care is needed. In addition, empirical studies of long-term recovery are sparse, allocation of funds may help facilitate research to fill the knowledge gap on long-term recovery management.
For Treatment professionals and treatment systems: If you work in routine healthcare and have patients with a severe substance use disorder, consider adopting a five-year monitoring plan of patient behavior and compliance (through urine or other biological matrices) along with measures of general health and functioning. Evidence of alcohol or other drug use may indicate the need for increased treatment from specialty services rather than the use of punitive responses.

CITATIONS

Dupont, R. L., Compton, W. M., & McLellan, A. T. (2015). Five-year recovery: A new standard for assessing the effectiveness of substance use disorder treatment. Journal of Substance Abuse Treatment, 58, 1-5.