US Surgeon’s General Report – Third In The Series.
When most of us think of addiction, the first thing that comes to mind is someone in severe distress, whose life has otherwise become unmanageable, whether he or she realizes it or not.
Someone who is in need of extreme care. The reality though, is that addiction is more like a sliding scale. Some people are more prone than others. Some become addicted more quickly and some find it easier to break the chain of addiction once it takes hold. The US Surgeon General report “Facing Addiction in America” (the ‘Report’) recently examined the state of our nation’s treatment protocols and provides some interesting perspective for all addiction treatment related businesses.
The general theme of the Report is “the sooner the better.” For that reason, it comes as no surprise the Report first emphasizes prevention related programs which we, of course, all strongly endorse. However, prevention is just our initial line of defense. Addiction is a powerful disease, and simple awareness is unfortunately not enough. When prevention is insufficient, we need to concentrate on treatment. That’s the point at which the concept of “the sooner the better” takes on an entirely new meaning.
The Vast Majority of Substance Abusers Begin Using While an Adolescent or Young Adult
Habits learned at a young age are much more difficult to break. The vast majority of substance abusers begin using while an adolescent or young adult. Moreover, drug use itself re-wires the brain. An adolescent or young adult whose brain is still just developing, never has the opportunity to develop a healthy, fully functioning brain. Finally, the earlier addiction treatment begins, the more quickly the brain has a chance to recover because, in most instances, the damage is reversible.
According to the Report, well supported scientific evidence demonstrates that, when identified early, substance use disorders can be effectively treated with recurrence rates no higher than those of other chronic illnesses (i.e. diabetes, asthma and hypertension). The problem is that medical care professionals have not been generally trained to treat addiction as a disease, nor in how to best engage someone showing early signs of addiction. We often miss out on a concrete opportunity to start treating the disease at its earliest stages. The current dogma of addiction as a chronic disease still hasn’t gained full traction. For that reason, patients also rarely voluntarily broach the subject or admit a problem. One study cited in the Report noted that patients were more likely to honestly report substance abuse tendencies through a stationed computer kiosk than directly to a medical care provider. This goes a long way to explaining why only 1 in 10 affected individuals, or 2.2 million people out of 23 million addicts, sought out treatment within the past year. It is clear that both patients and our industry could benefit greatly from community outreach and more direct communication with primary care and hospital physicians.
Another helpful early step is identifying populations most in need of early intervention.
Adolescents and young adults are an obvious start, but there are other distinct subgroups with a high propensity to addiction. People who binge drink (5 drinks for men, 4 drinks for women) on a single occasion at least once in the past 30 days, people who drive while under the influence and women who drink or use while pregnant, are such examples; basically anyone who demonstrates high risk behaviors as a result of drinking or taking drugs. If these people are approached at the early stages, in a non-judgmental way, with counseling tailored to their specific issue(s), they are more likely to be open-minded to seeking help before full blown addiction sets in. These early interventions can be encouraged in any number of settings, ranging from school clinics to free clinics and mental health facilities. The key element is giving care-givers the training and social license to approach individuals in this manner. Many might feel it’s beyond their expertise or bailiwick to promote substance abuse treatment when people are seeking help for other care. Patients may also be reluctant to accept such help in that environment. However, given our national addiction epidemic, now is no time to stand on ceremony. We need to break old conventions and create new ones that better engage potential addicts as quickly as possible.
The Report also discusses the complementary benefits of adding screening processes specifically designed to identify early-stage substance use abusers, administered via written questionnaires, medical tests, and through general healthcare observation. With greater awareness throughout the medical and patient community we will be in a better position to diagnose those most at-risk and get them into treatment before they are presented with more serious symptoms and consequences.
Only 10% Of Identified Addicts Seek Treatment
Now, at this point, you may be thinking that this is all just a wonderful utopian treatment. The rationalizations given by the non-treated include:
- 40.7% – Not Ready to Stop Using
- 30.6% – No Healthcare Coverage
- 16.4% – Have Negative Affect on Job
- 12.6% – Don’t Know Where to Go
- 11.7% Don’t Have Transportation
Moreover, people who seek treatment for addiction (under current traditional programs) have relapse rates ranging from 60-90%.
This would seem rather daunting, but I suggest the biggest hurdle we face is in our message, something we can change with mere willingness and conviction. Neither diabetes, asthma, hypertension, nor other like chronic diseases, have the rejection rate we face in treating addiction. They also do not have nearly the relapse rate, because most people take the long-term view of their health much more seriously with respect to those illnesses. In fact, evidence from studies in which substance abusing patients received effective treatment and then followed up with a long term model, had relapse rates comparable to other chronic illnesses. Relapse rates for substance use disorders then range from 40-60%, as compared to diabetes at 20-50%, hypertension at 50-70% and asthma at 50-70%. If we can get addicted patients and society at large to fully commit to taking addiction as seriously as we do other chronic diseases, then we can make greater strides in managing and modulating patient care.
This is actually a very realistic objective. The goals of substance use disorder treatment are very similar to those of other chronic diseases:
- Reduce the major symptoms of the illness
- Improve health and social function
- Teach and motivate patients to monitor their conditions and manage threats of relapse
It likewise also starts with a general assessment, exactly how bad is the person’s illness? Unfortunately, in the addiction treatment community, by the time the patients have reached our door-step, their conditions are usually moderate to severe.
There Is NO Cookie-Cutter Process to Treat This Chronic Illness
After a formal addiction assessment, the patient and facility develop a personalized treatment plan. This is where treating addiction like other chronic illnesses can get a bit tricky. The program needs to account for the patient’s age, gender, race, ethnicity, language, health, literacy, religion, sexual orientation, culture, trauma history and any co-occurring physical or mental health problems, all while maintaining the integrity of the principles of a proven Evidence Based Treatment Program. Moreover, while much can and should be gleaned from other past patients with similar profiles, each patient’s uniqueness ensures that treatment can and will never develop into a cookie-cutter process. In the context of the Report, it seems clear that in the paradigm shift of treating addiction like any other chronic disease, we may need to seriously re-think the entire process of how we provide treatment.
A treatment progression for someone with moderate to severe substance use disorder has typically been as follows:
- A 3 to 7 day medically managed Detox withdrawal program in an inpatient setting
- 1 to 3 months of intensive rehabilitative care in a residential treatment program (or Partial Hospitalization Program (PHP))
- A few months of 2 to 5 days a week of an intensive outpatient program (IOP)
- A traditional outpatient program that meets 1 to 2 times per month for at least 6 months.
This model has proven effective, but its weakness arises once the patient takes charge of his own recovery. At that point, he or she has gone through intensive therapy, behavior modification and re-education, and has been provided with life skills designed to help him or her maintain sobriety. However, there are often glaring disparities between programs in the types of therapies utilized and length of duration. Treatment for other chronic diseases is more standardized and includes greater monitoring over periods of time as long as 5 years. The Surgeon General’s Report noted that “although the field of treatment for substance use disorders has made substantial progress, additional types of research are needed.” It also pointed out that the industry could be better served by expanding monitoring and supervision of patients for an extended period of time.
So exactly how will we evolve into better application of the classic chronic disease model for addiction? One key way is greater use of Electronic Medical Records (EMR) which has grown dramatically over the last few years. EMRs like Kipu can play a critical role on many levels. We enable patients and medical practitioners to share treatment records for greater coordination of care, while simultaneously leading to improved quality and increased cost savings to health systems. Then, due to the fact we’re HIPAA compliant, we are also building a large de-identified, anonymous database which we hope one day can be used as a tool to gain insight for better molding addiction treatment into a more standardized model. At present, only about 20 percent of substance use disorder treatment programs have adopted EMR systems, according to the Report. Therefore, I strongly believe that greater adoption of EMRs will play a key role in the evolution of our industry.
Our nation has a long way to go in conquering the scourge of addiction. However, as they say, the most important part of solving a problem is recognizing its existence to begin with. The Report sets forth guidelines and frameworks which provide a great starting point. It’s now incumbent upon us to build upon this base and continue to increase awareness, while we adapt to the evolving landscape and develop best practices. Kipu’s recent acquisition of PingMD was completed with that in mind. It is a software we will be transforming over the course of the next 6-12 months to better serve our clients for treating patients in the early stages of addiction and with their ‘aftercare’ or ‘continuing care’ needs. Addiction treatment will always require a hands on approach, however, the Report strongly indicates that such is a necessary but not sufficient strategy for long term success. Technology will play a key, complimentary role as we all continue growing in serving our country’s urgent need in eradicating addiction.
As always, feel free to reply to this email and let me know what you think about this topic or share a topic you’d like me to discuss in the future.