Model of choice: a new addiction paradigm?

dr-julia-lewisTrends come and go and nowhere more so than in the shifting world of addiction management, says Dr Julia Lewis.

The pendulum seems to swing from one paradigm to another with the supporters of each frequently baying for the blood of their opponents. Some support abstinence as the only sensible goal, and berate the so-called ‘medical model’ with its alleged transfer of dependence to state-endorsed substances, while others shout loudly in support of what they claim is a more inclusive harm reduction approach. But what if there was a model that encompassed all these laudable ideas and then took things a stage further?

In 2007 the World Health Organization called the management of chronic disease (such as asthma, diabetes and hypertension) ‘one of the greatest challenges facing healthcare systems throughout the world’. Out of these concerns developed the chronic disease management (CDM) Model defined by the Disease Management Association of America as ‘a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant’.

Various researchers have argued that this model can be applied to the management of addiction, as evidence suggests that addiction has a similar profile to other chronic diseases. For instance, more than half of patients entering publicly funded addiction services in the USA achieve and sustain recovery after multiple episodes of treatment over several years, and addiction is associated with chronic physiological changes; a relapsing, remitting course; comorbidity; a need for ongoing care but with variable adherence to that care; and the absence of a ‘cure’.

Current models of addiction treatment provision in the UK frequently follow an acute care model, concentrating on the management of complications of use as opposed to the underlying condition, and lacking essential coordination of care across health and social care systems. However, managing addiction solely through these acute episodes of brief stabilisation and detoxification can contribute to the frustration of service users, their families and the public regarding prospects for permanent recovery.

Also, as a chronic disease with biological, genetic and physiological elements, addiction should be addressed via a case-managed combination of treatment modalities, personalised to the assessed needs of the service user, providing an integrated pharmacopsychosocial approach to treatment.

In contrast, the CDM model bases care on the service user’s needs, values and decisions, rather than reacting to problems. Nevertheless, transferring the CDM approach to the management of addiction requires a move into a recovery-oriented system and the recovery management (RM) model has been developed to combine these two treatment paradigms. So, what are the essential features of an RM model of addiction treatment?

The model is easy to access and geared to developing motivation. The care planning process focuses on the whole life of the service user, not just the problems caused by their use, and supports their right to manage their own condition. The clinician is seen as an educator, providing long-term support, and a comprehensive care plan brings together services best placed to address their needs. Interventions are evidence-based and include all relevant modalities, and the emphasis going forward is on self-management, with links to recovery resources in the community and easy access to re-intervention if needed.

It is possible that the RM model provides us with an integrated system of tried and tested addiction treatments but in a way that wraps the management plan around the service user, connects them effectively to other relevant parts of the health and social care system and draws on recovery resources in their community.

Accepting the chronic disease nature of addiction may be a difficult mindset shift for some, but to continue to attempt to address it via a model of acute, ‘one-size-fits-all’, circumscribed treatment not only does a disservice to our service users but also flies in the face of the evidence. It’s time to adopt the new paradigm.

Creating a shift in thinking from the traditional acute care models to the RM model is underpinned by the following concepts:

Addiction exists in transient and chronic forms. Transient forms may resolve spontaneously or with brief interventions alone. Chronic forms are associated with greater complications, more comorbidity and more obstacles to recovery.

Evidence shows us that, although recovery is an achievable goal, it takes around three to four treatment episodes over a period of eight years for this to occur.

If we see addiction as a chronic disease, we should not see previous treatment as a poor prognostic indicator, convey to service users the expectation of complete recovery after one treatment episode and punitively discharge service users who relapse.

Many people discharged from addiction treatment find themselves caught between recovery and relapse for weeks, months or even years, strongly supporting the need for ongoing post-treatment monitoring and support.

Multiple episodes of treatment, if integrated into a recovery management plan, can lead to cumulative effects and multidisciplinary interventions may have synergy.

Dr Julia Lewis is consultant addiction psychiatrist for Aneurin Bevan University Health Board. This article is based on her talk to the SMTPC event, The post-war dream, held in Newport, Gwent.