The State of Addiction Treatment

Addiction is a chronic health condition that affects 40 percent of the American public. It costs society about $600 billion annually, is responsible for 25% of all hospital admissions, and is implicated in 80% of incarcerations. Of the estimated 23-25 million people who need addiction treatment, about 2.5 million (10%) receive it. Stigma, insurance barriers, and the perception by many that they don’t have a problem have limited access to care. Efforts to reduce stigma through awareness programs, the 2008 Mental Health and Addiction Parity Act, and the influx of newly insured patients through the ACA have sparked new interest in expanding capacity, particularly inpatient treatment. Investors anticipate that the convergence of the aforementioned phenomena coupled with the surge in opiate addiction and overdose deaths will create a huge demand for detox and rehab treatment.

Despite these factors and wider acceptance of addiction as a chronic brain disorder, systems of care continue to be primarily developed and defined by acute, time-limited treatments. This fragmented approach fails to provide the life-long management necessary to achieve sustained remission. Data from the Massachusetts Information System reveals that 87% of patients admitted to detox units have previous admissions; over half have been there more than five times. Of an estimated 40,000 detox admissions last year, 53% or 21,200 were patients who have been to detox five or more times. If the admissions for these patients could be reduced from 53% to just 45%, it would free up bed space for 3,200 patients; if we could reduce it to 40%, it frees up enough beds to admit more than 5,000 patients. Similar data exists for long term residential programs where 75% of patients have been there multiple times. Yet, the existing system encourages and reimburses bed care and underinvests in community based care management. Anecdotal reports from providers indicate that patient transitions from inpatient to outpatient care are poor, ranging from to 25-50%. While the system surely is suffering from a temporary dearth of inpatient capacity, the greatly underemphasized problem is the absence of substantial and comprehensive community based continuing care management and the paucity of prevention, early identification and intervention.

The Failed Addiction Paradigm

For more than forty years, addiction treatment has been defined and judged by the misplaced perception that a fixed amount or duration of treatment (a week in detox or a month in rehab) will “fix the problem”. If the patient regresses after leaving rehab, it is often attributed to the patient’s lack of readiness or to ineffective treatment. While acute detox and rehab care are integral in any treatment design, they are not the template for treatment of a lifetime chronic condition. Patients must be treated in a seamless array of services matched to the severity of their condition or need and that treatment must be sustained beyond a time limited episode.

The Gosnold Experience and Experiment

While opiate dependence is not limited to any single demographic group, those most affected are young adults. In the last six years, Gosnold admissions for this age group has risen from 27% to 45%! Many young people are getting to treatment and this is a good thing. However, closer examination of the data is not as encouraging.

We tracked a sample of 65 young patients during and after their detox treatment. Among them,

• 96% reported a supportive family, girl/boyfriend, or twelve-step colleague.

• 93% successfully completed their inpatient treatment.

• 91% accepted a referral to continue their treatment at another level of care

• 40% to an inpatient or long term residential treatment program.

• 36% to an intensive outpatient program

• 15% moved into sober living residences

Yet despite these positive indicators of motivation, follow-up contacts revealed that:

• Only 53% kept their initial continuing care appointment

• Only 23% kept their second appointment

• 13% had already regressed (resumed use) within 72 hours of discharge

• 17% had regressed by the second call, 7-10 days later

These patients were motivated to seek treatment and remain drug free. They were engaged in their care! And they had supportive family and others who cared about them. Yet, nearly one in five regressed within one week following discharge. We must find better approaches to improve remission rates and successfully bridge the gap from a detox or rehab treatment to community based care.

What Did We Do?

We developed a service that we believe is helping to improve treatment outcomes. It includes several components, the centerpiece being highly personalized and customized recovery coaching that is introduced before a patient is discharged from an inpatient treatment episode.

1) Recovery Coaching and Care Management

Gosnold certified Recovery Coaches are available 24/7 to help patients as they transition from an inpatient program. They develop a Recovery Wellness plan with patients that focus on recovery activities, navigate high risk situations, strengthen their recovery life, and extinguish the drinking and using lifestyle. The coach guides the patient in decision making about daily activities--the day’s schedule, meeting attendance, employment or school plan, etc. They conduct home visits, meet with family members or significant others, connect patients with community resources for medical care, education, employment, recovery oriented social activities, primary care physicians and dentists, transportation needs, access to entitlement programs, and other similar activities.

2) Medication Assisted Treatment

We aggressively promote the use of the antagonist medication, injectable Vivitrol, and integrate it in our inpatient and outpatient programs. We chose Vivitrol for its time-release feature that eliminates non-compliance that frequently occurs with orally administered medication. We currently have nearly 400 patients maintained on this medication. Vivitrol is used as part of a comprehensive plan that includes counseling, community based recovery supports, and other psycho-social interventions.

3) Psycho-Social Clinical Interventions (Individual and Group)

We employ all of the direct treatments traditionally used including individual and group counseling, intensive outpatient programs, inpatient detoxification, rehabilitation, and residential services, and peer influenced support groups. These programs use evidence based approaches including Cognitive Behavioral Therapy, Matrix based IOP, and Solution Focused Therapy.

4) Technology Assisted Recovery Management

We use Smartphone applications to maintain contact with patients and encourage them to connect via this technology to other patients in recovery. Patients are invited to download the application and become part of the Gosnold recovery community. A Gosnold Recovery Coach monitors progress and serves as their principal contact. Participants check-in daily to report on recovery status and identify recovery risk factors. Deviations from norms are communicated to the Gosnold coach who initiates personalized interventions with the patient. Patient have access to a “panic button” which, upon activation, alerts the coach that the patient is in crisis or danger of relapse. The application allows patients to link into recovery support forums for discussion groups, listing of recovery socialization activities, twelve-step meeting calendars, recovery news, podcasts, meditations, and other supports that enhance recovery.

5) Family Support and Coaching

At time of discharge from the program, the family, patient, treatment staff, and recovery coaches meet to review the continuing care plan, coaching schedule, and early recovery objectives. Family members are given contact numbers to enable communication of concerns to coaches. Gosnold’s Reaching Out family program assists with coaching support, addiction education, support groups, family intervention, and family counseling.

6) Recovery Socialization

We recognize that coaching to simply ensure treatment compliance needs to be balanced with activities that enable patients to experience enriching and interesting lives. We engage patients in ski trips, deep sea fishing, fitness programs, competitive running, concerts and cultural events. They begin to see life in recovery as something exciting, not just trips to counselors and meetings.

7) Drug Testing

Random testing is overseen by the Recovery Coaches and occurs whenever deemed advisable. Patients on opiate blocker medication undergo testing as part of the pharmacological protocol. Positive screenings are sent to a drug testing laboratory for confirmatory testing. Positive tests result in an intensification of the treatment and oversight protocols.

8) Concurrent Recovery Outcomes Monitoring

We monitor patient outcomes at intervals using Recovery Track, a web based software application developed by Treatment Research Institute. We track nearly 30 outcome domains that include substance use, risk factors, protective factors, health and well- being, and utilization of treatment services. Graphical displays of progress over time can be viewed by the coach and patient and used guide care planning.

The Results

As of March 2015, 97 individuals have participated in the program. Following is data on the progress of participants who have completed a minimum of three months in the program (n=56). Forty-one (41) are either inactive or have not yet reached three months of participation. The sample includes 29 males and 27 females, ranging in age from 18 to 29.

Days in Remission

On average, participants achieved 253.94 days of sobriety compared to an average of 64.05 days in the year prior. Overall, participants increased their sobriety percentage from 17.55% in the year prior to YAOP to 78.34% of YAOP participation. Significantly, among those who regressed, the average time between resumption of use and a return to stabilization treatment was 5.43 days. Readmission rates to Detox and Rehab programs were substantially reduced.

Medication Assisted Treatment and Safe, Supportive Living

In the year prior, 5.36% of the sample participated in medication assisted treatment. This rose significantly to 48.21% during program participation. In addition, 34.1% had reported living in sober, supportive environments in the year prior to program participation compared to 93.5%.

Employment and Legal Incidents

Participation is also improving social aspects of an individual’s life such as employment and legal issues. Days employed increased from a total of an average of 7.14 days worked per month to 15.04 days during program. Only 5 individuals (M=0.12) had legal issues compared to 19 (M=0.34) the prior year.

The outcomes inn this pilot project demonstrate that a comprehensive extended care management approach can increase sustained remission rates, and reduce stresses on the inpatient treatment system, the legal system, and hospital utilization rates. We are now accumulating cost data to determine the cost savings that may be realized.

The Future: Integration of Prevention, Treatment and Recovery Management

Chronic disease management thinking is central to policy and care system development. Treatment, prevention, and management need to reside on a single continuum that eliminates the barrier of “program” thinking. We must no longer consider a patient “discharged” with its implied message that they are “finished” with treatment. Many of the components of the continuum must be integrated into the mainstream of healthcare. Patients with this disease and those at greatest risk to contract it must be served in a system that enables them to be cared for at any point on the spectrum be it a hospital, a doctor’s office, a clinic, or a specialty treatment center. In addition to the extended care management described above, we must incorporate features on a scale necessary to effect real change.

• Integration with Primary & Specialty Medical Care

The isolation of addiction services reinforces its separateness from general medical care, thus perpetuating the crisis orientation. Clinicians working side by side with professionals in the physician’s practice enables universal screening, early identification, and intervention. Integrated care helps normalize the highly stigmatized conditions of addiction. It provides opportunities to identify high risk patients and initiate treatments, and educate lower risk patients to appropriate lifestyle modifications to minimize future problems. Behavioral interventions in the management of chronic conditions that have high co-morbidity rates with addiction (diabetes, depression, chronic pain, GI disorders, etc.) can also be effective in early identification. This shift to an integrated system will require a shift in resource allocation, workforce development, improved reimbursement mechanisms, and modifications in regulatory and licensing standards. We are presently operate pilots in three primary care practices, two ob/gyn specialty practice, a community health center and a pediatric practice.

• Addiction Specialists in Hospitals to Manage Patients undergoing Alcohol Withdrawal

25% of hospital admissions have an underlying alcohol dependence disorder and untreated alcohol and/or drug abuse increase costs, length of stay, service utilization, and stress on the medical staff. Yet many hospitals pay little attention to the condition, often minimizing or ignoring it, in part because of lack of training and an uncertainty about how to engage with the patient. Addiction specialists can help improve screening tools and methods, oversee the management of withdrawal, and train staff to be more compassionate and better prepared to treat these patients. A Gosnold led project at a local hospital resulted in significant reductions in ICU transfers and lengths of stay. The requirements are a willing hospital, training and workplace learning by a subject expert, and hospital management support.

• Extended Engagement Services with Recovery Coaching

Our success with recovery coaching has led us to expand its scope and collaborate with area police departments to assist them with overdose intervention services.

• Medication Assisted Treatment

Medication that enhances one’s recovery is important in any treatment protocol and does not force separation into ideological camps of “harm reduction” or “abstinence based”. The semantic debate about these positions compromises our voice in the public policy arena. We all do “harm reduction” and we all can subscribe to “abstinence”.

• Technology Based Interventions and Tele-Health

In addition to the Smartphone apps, tele-psychiatry program can improve access to psychiatric evaluation and medication management.

• Prevention that Engages Schools, Parents, and the Community

Counselors in elementary, middle, and high schools help students manage behaviors that make it more possible for them to achieve academic goals. Intervention at the elementary level enables early identification of at-risk kids. In the higher grades, school based clinicians can work with troubled students and support activities that influence school culture. While the school may be the base from which prevention activities spring, they must be extended to the family and to the larger community. We are bringing these services to the community through awareness forums, educational lectures, and support groups. At the community level, we coordinate Drug Take Back days, pre-prom anti-drinking campaigns, clergy training seminars, conduct “Parents who Host, Lose the Most” sessions, sponsor Sticker Shock initiatives, offer “Guiding Good Choices” seminars, and engage in other prevention activities. Seminars are offered to medical professionals covering topics such as prescribing practices, managing pain with opioid medications, and treating opiate dependency.

We must bring all these elements together--treatment, prevention, early intervention, research, and innovation. Core services across the spectrum of care--Inpatient and outpatient detoxification, rehabilitation and extended treatment, day/evening programs, outpatient services, medication assisted treatment, and other clinical elements; comprehensive follow-up care with personalized coaching and technological supports; linked more closely to mainstream healthcare, invested in prevention, early intervention, and integration with hospitals and primary and specialty medical practices. And, participation with our partners to advance addiction treatment through innovation and research. It is a formidable undertaking but it can be done.

BARRIERS TO SYSTEM RESDESIGN

There are several impediments to the creation of a more comprehensive system of care.

1. Allocation of Resources

The bulk of dollars spent pays for the consequences of addiction—social welfare, other health costs, criminal justice, etc. A Columbia study showed that for every dollar Massachusetts spends on substance abuse, one penny goes to treatment, one penny goes to prevention, and the other 98 cents is spent of the consequences of addiction. We need to correct this imbalance.

2. Reimbursement

The current level of reimbursement to providers is entirely detached from the real cost of providing comprehensive services. Rates in outpatient programs have been static for years and in Massachusetts, 84% of outpatient providers who treat privately and publicly insured patient report significant deficits. Public and private reimbursement structure limits providers and discourages innovative approaches. Yet much of what needs to be done, needs to be done in outpatient and community settings.

3. Regulation

Regulations, while well-intentioned, often serve to micro-manage programs, inhibit efficient operations and stifle innovation and creativity. Many are antiquated and archaic in today’s rapidly changing healthcare environment.

4. Innovation and Outcome Research

Programs are not incentivized to innovate. We need to encourage investment in new ideas and create an entrepreneurial spirit in our industry. And we need to fund the research necessary to find better medicines and treatments, and measure effectiveness so we can invest in what works.

5. Workforce Development and Outcome Research

Qualified and trained professionals are in short supply. It is vitally important that we attract individuals into the field and develop, train and support the doctors, nurses and counselors. Tuition reimbursement, curriculum development, and provider incentives can help.

The impact of addiction on our society has been brought to the forefront of public attention because of opiate overdose tragedies. It is unfortunate that it has taken this long to recognize a problem seventeen years in the making. A lasting legacy to those who have perished is to build a system of care that addresses the chronic nature of addiction and the need for life long management.

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