One of the biggest issues regarding addiction and the treatment of this deadly disease is the way that we approach treatment for substance use disorder throughout America. The opioid epidemic, and on a greater scale the overall addiction epidemic, has thrown the United States into a crisis and in doing so, exposed many issues with how we approach and treat the disease of addiction.
For years, addiction treatment was a bastard stepchild of healthcare. Little training was given to medical professionals and therefore many doctors did not feel comfortable dealing with the addicted population. Hospitals, many influenced by the stigma of addiction, offered little to no resources for addiction, some going so far as to take the stance of not wanting “those type of people” intermixing with their patient population. A select few dedicated medical professionals entered the field to provide services but most treatment was ultimately provided by two categories of people: therapists and other mental health practitioners that had been educated on addiction and individuals in personal recovery that had a vested interest in offering services to those suffering from the disease.
The model typically used was the 30 day model of residential treatment. This model of the 30 day rehab is still the model that society as a whole still views as to what addiction treatment is supposed to look like. Patients would often leave their local area to admit into a safe campus-like or hospital-like atmosphere, if necessary be detoxed off of substances, and receive treatment for the remainder of their stay. The approaches towards treatment differed slightly, often being either 12-Step focused or more clinically-focused, but the optics were the same: If you needed help for addiction you needed to be shipped off to a rehab for 30 days. There were many reasons that this model became the standard of care for addiction treatment, none of which were clinically-driven. However, the fact remains that for many people with substance use disorder, a 30 day stay of detox and stabilization in a residential treatment environment away from their local community is often necessary to begin a journey of recovery.
Sometime later outpatient treatment facilities began operating in communities throughout the country. Patients would show up to an office for a set number of times a week and receive treatment services while still living at home in their local community. This type of care became attractive for certain types of people such as working professionals who needed help but wanted to remain at their job or career or single parents who had children to care for and little or no family help or support. In short, people whose personal situation perhaps made it extremely difficult to go away for 30 days in order to receive treatment.
More recently, especially in the light of the opioid crisis, there has been a push to Medication-Assisted Treatment (MAT) services, which in actuality has been taking place since methadone clinics opened, but more recently is discussed in terms of the prescribing of Suboxone or buprenorphine to addicted individuals by a doctor. Medical practitioners became legally allowed to treat people with addiction from an office setting, seeing a capped number of patients at a time and prescribing medication. More recently, the medication Vivitrol has entered the picture and many pharmaceutical companies are working on other implantable medications to deal with people suffering from opioid use disorders. It is important to note here that many of these medications, excellent tools in treating addiction, are just one tool in treating a complex disease and should be used when clinically appropriate as a supportive tool as part of a comprehensive clinical treatment program. Unfortunately, many programs or providers simply utilize these medications AS treatment without mandating patients be involved in other therapeutic or supportive services. Believing a single doctor has the ability to “treat” 275 patients suffering from addiction as an individual provider simply by prescribing a medication is clearly incorrect and ignorant to the complex issues faced by an individual with substance use disorder. The fact that many do not mandate counseling at a minimum, is insane.
So the question is, how does the public know what to do when an individual or a loved one suffers from addiction and is in need of treatment? What should treatment ideally look like in order to ensure the best outcomes? With the addiction crisis in America rising, with numerous profiteers jumping at the chance to profit or benefit off addiction (pharmaceutical companies, medical professionals, unethical treatment centers and others), how does the public know what to believe, who to trust and what to expect in terms of treatment?
Above all, there is one thing that we know is effective in treating addiction and providing successful recovery outcomes: A long-term continuum care that includes continued patient monitoring, family outreach and support and vital enrichment services such a college, vocational or workforce training and reentry program. For evidence, look no further than the standard set by Physicians’ Health Programs or those programs designed for airline pilots dealing with substance use disorder. These programs, designed as continuums of care for those specific professionals and lasting for 5 years in length, have demonstrated successful outcomes between 72%-90% for patients. These programs include necessary clinical services based on the individual needs of the patients as well as five years of monitoring and random drug testing. The results speak for themselves.
Therefore the question becomes: How do we create similar outcomes for the everyday person suffering from addiction? How to we create similar programs and allow access to them for the regular citizen? The answer again revolves around a long-term continuum of care. The idea that remains in the minds of the general publics that “treatment” equates to a 30 day rehab stint must be obliterated and replaced with the education that addiction is a chronic, progressive, ultimately fatal disease if left untreated and which must always require comprehensive, long-term care. This must occur through a continuum of services from a single treatment provider or several providers working together in order to provide the appropriate clinical services to a patient and their family.
So what does that look like? First, it’s important to quickly break down those levels of care.
Detox: Detox is typically the first step in the continuum, a medical necessity for many people dealing with specific substances. Depending on the substance(s) being used, an individual may need anywhere from 5 to 14 days to physically detox.
Residential/Inpatient Treatment: Residential or inpatient treatment n is often utilized simultaneously with detox, meaning that most residential or inpatient treatment centers will have detox services on their campus. Residential treatment or inpatient treatment is your traditional 30 day model and would be considered an acute level of care. Residential treatment nearby is often vital in giving a patient the time away from their environment to detox, medically stabilize and then begin the treatment process. Sometimes the residential stay can extend past 30 days to 45 days, 60 days or even longer. There are often very few actual barriers to someone going away to a rehab other than the excuses they make for themselves. Remember “I can’t go” is not the same as “I don’t want to go.”
Extended Care Residential Treatment: When transitioning from a residential level of care, the next appropriate step in the continuum would be an extended care residential treatment program. Some states have a specific licensed for this type of level of care and some do not, but what true extended care looks like is typically clinical treatment services each day while living in a staffed residential location in the evening. This would be the next appropriate level of care for a patient suffering from addiction, as it transitions them to intensive clinical services but with some more personal freedom and the opportunity to begin independent living and life skills building in a supportive clinical environment. It is important to note that true extended care is a full program with clinical and trained residential staff working together, similar to an inpatient rehab and does not mean an intensive outpatient (IOP) program while living in a recovery house with a house manager. Outpatient services and a recovery house can be part of a continuum of care, but are not the same this as a comprehensive extended care residential program.
The next step in a continuum could look different based on the individual needs of the patient. It could include moving from extended care into a sober living environment like a recovery house while attending a day treatment program (a partial hospitalization or PHP level of care) or while engaged in a lesser level of clinical services known as intensive outpatient (IOP.) A PHP level of care is typically around 25-30 clinical hours a week while an IOP level of care is often 9-15 clinical hours a week. However, at this point in the continuum, it may be suitable for the patient to be engaged in one of those levels of treatment while returning home, depending on the supportive nature of that home environment.
It is important to note that throughout each level of care, the patient is being randomly drug tested when clinically appropriate. This means once or twice a week unless they have been out on a pass or there is a concern by the clinical staff that a relapse may have occurred. Additionally, the patient’s family is regularly brought into treatment for family sessions or engaged in phone or Skype sessions. In conjunction with that engagement with the treatment program, the family would have attended family education weekends and the clinical staff at the treatment center is also in constant contact with the family members offering support, coaching and education regarding the patient’s issues and behaviors. Recommendations may also be made to family members to programs like Al-Anon, local parent support groups or to individual professionals so that families may begin to get their own help for issues surrounding their loved ones addiction.
Furthermore, at some point in the treatment experience for a patient, treatment programs should be offering them the necessary support, training and direction in creating a purpose-driven and meaningful life. This is often in the form of a college, workforce or vocational training and reentry program. The treatment center(s) need to provide assistance in this area for patients, along with life skills building. This occurs within the clinical setting of treatment, so patients learn the necessary living skills but also are able to overcome life barriers that could cause issues moving forward, such as legal issues, budgeting, and a lack of education, divorce or debt issues.
Past a PHP or an IOP level or care, a patient would then transition to perhaps several clinical hours of outpatient treatment or perhaps would move on to see one or multiple individual providers such as an individual therapist or a psychiatrist. This may occur while the patient has transitioned out of the addiction treatment program or while they are still enrolled in an outpatient level of care. At this time the patient may be living at home or still in a recovery house.
The basic understanding is that families should need to be informed and educated that addiction IS a disease and that a chronic, progressive disease that impacts EVERY aspect of an individual’s life needs long-term treatment that address every one of those impacted areas. Treatment cannot just be therapy. Treatment cannot just be a medication. And treatment cannot just be rehab and right back to everyday life. Treatment must be comprehensive enough to deal with the substance use, the underlying and core issues, mental and psychiatrist issues, trauma, potential sexual and/or gender issues, relationship issues, family dynamics, lack of motivation and purpose, education or employment issues, life stills development and living situation. This takes a long-term approach through a continuum of care. Addiction impacts and influences each of these areas of a patient’s life and therefore treatment, as a whole in a comprehensive continuum, needs to address each of these areas as well. Families must understand there is no quick fix. If parents had a child suffering from cancer and their doctor laid out the 5 year plan that would provide the best potential outcome, there would be no questions asked. The suffering loved one would immediately engage in that long-term treatment plan. However, based on the misunderstanding and stigma of addiction and the nature of the addicted individual, patients and even families often fight tooth and nail against what is recommended and what is necessary.
The mortality rate of addiction is growing and opioids alone are causing the death rates in America to rise exponentially. This is preventable and this is certainly treatable, but the public needs to come to see addiction as a health issue and embrace the understanding of what works best. A chronic progressive illness requires long-term care, monitoring and support. Medical professionals and pilots have programs that offer evidence of a 5 year plan with extremely high success rates. Don’t our family members and loved ones suffering from addiction deserve the same success? Of course they do, but if we want that for them we must come to an understanding of what they need, what to expect and how to support them in receiving necessary long-term treatment to facilitate long-term, sustainable recovery.
If you or someone you know is in need of help because of drug and/or alcohol abuse or addiction, please give us a call. Maryland Addiction Recovery Center offers the most comprehensive dual diagnosis addiction treatment in the Mid-Atlantic area. If we aren’t the best fit for you or your loved one, we will take the necessary time to work with you to find a treatment center or provider that better fits your needs. Please give us a call at (410) 773-0500 or email our team at [email protected]. For more information on all of our drug addiction and alcohol addiction services and recovery resources, please visit our web site at www.marylandaddictionrecovery.com.