I went to an addiction conference the other day given by a national expert. He said his addiction program can’t help all patients and has had to turn away many patients and refer them to other treatment centers, saying; “That patient doesn’t fit my program!” This sentiment was shared again and again by different noted experts in the profession of substance abuse and addiction.
The internal medicine doctor in me just can’t quite understand this, but the addiction specialist in me understands where they are coming from. We need, however, to change our own way of thinking about treating the addicted patient if we are ever going to establish long-term success in this highly complex medical profession.
What about designing programs to fit patients and not patients to fit programs?
Medical Care Model
If a patient is having an acute coronary syndrome, he is admitted to the CCU and placed on blood thinners. As he stabilizes, he is transferred to the telemetry floor for close observation and as he improves he is transferred to another unit and then eventually to home and then rehabilitation. This is a standard of care shared by most physicians and hospitals in the nation. If his condition changes at anytime he may transfer back to the CCU and eventually undergo surgery. Then he can start the process over again.
Likewise, if an opiate addict appears with comorbidities such as diabetes, cardiac conditions, febility, or co-occurring addictions such as, benzodiazepine addiction perhaps they too should be detoxed in an acute care facility
Psycho-Social Addiction Model
If the patient is referred to treatment in the substance abuse experimental phase, perhaps they should be admitted to a psycho-social model much as we treat hypertension, diabetes, or high cholesterol with diet and exercise before they develop into a cardiac condition.
Note: With any of the following treatments if the patient’s behavior compromises other people, then perhaps he should be incarcerated.
SBIRT (Screening Brief Intervention and Referral to Treatment) may be the appropriate intervention for a patient in the substance abuse phase.
Once the opiate addict becomes addicted and the patient shows physical withdrawal symptoms, perhaps he should be detoxed and referred to an appropriate IOP (Intensive Outpatient Program).
- Non-Medicated. An example of non-medicated IOP is abstinence with no use of pharmaceuticals.
- Medicated. If this diabetic-like patient can’t control himself with abstinence, then maybe we should add pharmco/therapy such as Suboxone or Naltrexone just like we would add Junuvia, Glucophage, or Actos to a diabetic patient who is unable to be controlled by diet and exercise.
If the diabetic patient fails to achieve control and oral agents are not working, we up the level of care and add insulin.
If the patient can’t be controlled on Suboxone and continues to flip flop between Suboxone and illicit drugs, maybe we should change the therapy to long acting Naltrexone, just as we do if the diabetic patient fails on glucophage; we then may add insulin in this situation, also.
If the patient’s opiate addiction comes under control, then maybe we should discontinue our pharmco/therapeutic aids and encourage our patients to remain in a therapeutic community such as 12-step to continue his control over his disease.
If an addict fails to be controlled in an IOP program then he should be sent to a residential treatment program. As his condition improves then he should be transferred to sober living and back to IOP.
Long Term Treatment
If a patient cannot achieve control in a residential treatment program, then we should transfer him to a higher level of care such as another center or an island or one that is isolated in the mountains far away from any drug supply.
Once back at home, if the patients condition changes at anytime such as a relapse generated by an acute life stressor, we change the level of care again until the patient is stabilized.
If we as treatment providers are calling addiction “a brain disease” and everyone does agree on this definition, why don’t we use the same medical model we use to treat heart disease or diabetes?
Why can insurance companies approve and determine lengths of stay based on artificial criteria established in a book with no evidence based results and not by the patient’s response to treatment? My cardiac patients are not denied readmission to the CCU just because they have been there before. My diabetic patients are not given one lifetime treatment to control their diabetes.
I have seen insurance companies approve a three-day length of stay for opiate detox regardless of the length of time the patient has been on opiates, the amount of opiates the patient uses, or whether it is a long acting or short acting opiate. Patients on methodone or oxyconton may not even start to withdrawal until the third day of abstinence.
Why are insurance companies allowed to give one lifetime treatment for a chronic relapsing disease when science has repetitively proven genetic and neuro chemical aberration in the addicted brain?
There is no magic bullet when it comes to treating an addicted patient. We use our best medical judgment and skill sets to help them. Yet our community of substance abuse providers cannot agree on what works or when or what program goes where. Our own statistics of outcomes, largely that most programs do not work and that only repetitive intervention provides the best clinical model of long term success, underscore this concept.
Only when we can collectively begin to diagnose, treat and follow our patients under agreed standards of care and protocols will our current approach change for the betterment of our patients. The pendulum has swung too far against our patients that it’s time to push it back toward the center so that our patients, our insurance industry, and ourselves can evolve.
Insurance companies should authorize the level of care the patient needs and not by what the insurance industry needs. Criteria should be established on a medical model and not a business model. It’s working for treating diabetes, hypertension, and heart disease, so why wouldn’t it work for treating the chronic relapsing disease of addiction?
So let’s improve the level of care needed by the patients and the duration that they require by designing programs to treat and fit our patients instead of trying to find patients to fit into our programs.