A Final Perspective

The last section of the Surgeon General’s 2016 Report (the “Report”) is entitled “Vision for the Future: A Public Health Approach”.  It was primarily a summation of the entire Report but also provided some final compelling statistics.  They saved some of the most interesting facts for last to keep our attention.  It also gave me a chance to gather my thoughts toward honing a vision of a bird’s eye view of
\the entire addiction treatment process.
1. More than 10 million full time workers have a substance use disorder.  This is a leading cause of both disability and reduced worker productivity.  Addiction, in general, and the opioid epidemic, in particular, have been blamed for a large percentage of people no longer represented in the workforce, helping to explain the anomaly of low wages and inflation, during a corresponding period of relatively low unemployment.
2.  Only 8 to 10 percent of schools actively provide structured drug prevention programs.  This is beyond incredible considering all of the evidence pointing to the fact that addiction is a disease that clearly initially manifests most commonly in adolescents and teenagers.
3.  Only 10.4 percent of people with a substance use disorder receive treatment (is it a coincidence that this correlates to drug prevention programs?) and of that 10.4 percent, one-third receive only the minimal standard of care.
4.  27.9 million people self-reported driving under the influence in the year prior to the survey.  This jibes with a report entitled ‘Results of the 2013-2014 Roadside Survey of Alcohol and Drug Use by Drivers’, conducted by the US Department of Transportation’s, National Highway Traffic Administration, which found that approximately 8% of drivers in the US test positive for alcohol on any given weekend evening, with 2% exceeding the legal limit.  It also helps to explain the more than 40,000 automobile deaths last year, the highest since 2007, since over one-third were attributable to impairment by drugs or alcohol.
5.  More than 300,000 deaths have been avoided in the past decade simply from implementation and enforcement of effective policies to reduce underage drinking and DUI.  (Will this be undone by the widespread growth of adult and underage marijuana use?)
6.  Forty five percent of patients seeking treatment for substance use disorder have a co-occurring mental disorder.
7.  Only 8 percent of American medical schools offer a separate required course on addiction medicine, and only 36 percent offer it as an elective.
8.  The Mental Health Parity and Addiction Equity Act of 2008 and Affordable Care Act of 2010 increased access to coverage for mental health and substance use disorder treatment services for more than 161 million Americans.  (Exactly how, and to what extent, this might be undone by future legislation remains to be seen.)
9.  The Surgeon General’s Report on Smoking and Health was released in 1964 and it took several decades for its impact to take full effect.  We must utilize lessons learned from that report, and its extremely positive results, to shorten the time-frame in fighting addiction.
10.  Even serious substance use disorders can be treated effectively, with recurrence rates equivalent to those of other chronic illnesses.  More than 25 million people with a previous substance use disorder are estimated to be in recovery.
11.  Individuals at all levels within the addiction spectrum can benefit from treatment.  However, only those with the most severe disorders typically receive treatment.  Only approximately 10% of people who technically qualify as addicts seek treatment.
It is with these last two points in mind, and many of the other lessons learned from the Report, that I’ve designed what I’d like to refer to as the Addiction Care Continuum.  Much of it we already inherently know as addiction treatment executives and professionals, but I strongly believe it would be helpful to share a stronger commonality of language and process in our addiction treatment stratagems.  So, below please find my perspective for nurturing an improved treatment approach, followed by a flowchart of treatments and outcomes (including the likelihood of incarceration, which plays a big role in relation to addiction and will be covered separately and in detail in a future article).
The continuum and terminology I propose are as follows:
  1. Pre-Addiction
  2. Early Stage Addiction
  3. Addiction
  4. Recovery Bound
  5. Near Term Recovery
  6. Long Term Recovery
This is the point at which someone who is pre-disposed to addiction has still not been exposed in a meaningful way to the trigger that will bring it on.  A knowledge and understanding of family history plays an important part, since the child of an addict has over a 40% chance of being one as well, and that percentage jumps dramatically if both parents struggle with addiction.  This is the phase at which “At Risk Education” (education emphasizing prevention) is most critical and effective.  It should be focused on pre and early teens who are most at risk to, and most in danger from, addiction.
At this juncture, general physicians, psychologists, social services, our treatment center community, and other general mental and physical health providers are in the best position to guide someone towards treatment.  Treatment is now also most cost-effective and patients most open-minded.  Treatment typically can be implemented with sufficient impact via group sessions in a formal IOP (intensive outpatient) format, or via informal groups like AA, several times a week.  This should be combined with an online support program, strong family involvement in the process, and occasional testing for substance abuse, depending on the severity level of the addiction.
This is the stage we are most familiar with.  The addiction has risen to the level of materially and detrimentally affecting the life of the addict and his or her loved ones.  Treatment might begin with Detox, any other number of inpatient options, or perhaps even with regular but extensive outpatient services, again, depending on severity.  The individual is in critical need of both eliminating the physical craving for the substance and the euphoric recall creating a mental reliance.  Treatment through this phase involves extensive therapy with the objective of getting the patient into a state of sobriety or, in certain circumstances, extended care through Medically Assisted Treatment (MAT).
Typically, everything post-addiction is considered in ‘recovery’ and the related treatment during this phase universally termed as ‘aftercare’.  However, people in recovery have different needs depending on the specific phase they are in post treatment.
Recovery Bound is envisioned as a new level of care which acknowledges the fact that the first year after achieving sobriety (or relative sobriety via a MAT) is the most challenging.  Most relapses occur during the Recovery Bound period as the addict is released back into the world with less than a full appreciation of the difficulties in maintaining sobriety and the temptation that lurks around every corner in the form of familiar ‘people, places and things’ that once led him or her to use.   Some treatment centers offer aftercare but there’s very little consistency from location-to-location and, more importantly, in the stringency of ensuring patient compliance.  Let’s face it, virtually all treatment centers specialize in getting the addict to the point of recovery, and do a very good job.  Very little funding is offered for aftercare by either government programs or insurance companies.  That poses a distinct tangible impediment.
The one-year Recovery Bound phase is an intensive program that recognizes the unique problems addicts face as they begin their lives anew.  It requires extensive out-patient follow-up, regular testing for substance or alcohol use, group support, family involvement, and inclusion in an online program (via both web and an app) to ensure strict compliance and re-enforce the positive behaviors learned during addiction treatment.  Our recent acquisitions* of PingMD and “In Recovery” magazine were made with this stage and the Near Term Recovery stage (that follows) in mind, because of the urgent need for strict, affordable aftercare based on a technology platform tailored for the under-served community of addicts in recently hard-won recovery.  KIPU intends on rolling out a program later this year to cater to specific needs of this recovery group.
This covers the period of years two through five after sobriety (or relative sobriety).  The Report clearly recognized that by treating addiction with a five year plan, like we do with all other diseases, we can create outcomes that result in an 85% success rate.  Yet, it’s rare that people in recovery are given this level of attention.  After the Recovery Bound phase, the addict’s needs are diminished but still significant.  They require regular follow-up and support.  Most of this can be provided with online support and monitoring, through apps, group sessions online, telehealth therapy and predictive analytics to anticipate relapse and warn the addict and his or her family in advance.  Among other elements, this involves regular reminders, occasional testing for substance or alcohol use and technological platforms for 24 x 7 x 365 support (24 hours a day, 7 days a week, 365 days a year) including dedicated help lines to contact during moments of weakness.
This final phase simply reflects that addiction is a lifetime disease.  One cannot be cured of addiction.  Addicts must constantly be vigilant and have a healthy respect for their disease, just like a diabetic, or it will literally kill them over time.  Very much like cancer, being cancer free for 5 years after treatment offers great hope of a lifetime without recurrence of an episode from the disease.  Addiction is very similar; 5 years of sobriety is a major achievement and a great indicator of a sober future, but it is no guarantee.  Addiction is never gone.
This is the final article in my series on the Report.  I’ve learned a lot in this process and have thoroughly enjoyed gaining new insights and perspectives on this journey with you.  As we go to work and do our jobs, day-in and day-out, we are prone to get caught up in our routine and begin to feel as if we know everything there is to know about what we do.  That can be a trap.  Oftentimes, moving forward requires taking a step back, to reflect on what we think we know.  In the process, we can find out that there’s a lot we don’t know that we didn’t even know existed.  That’s the challenge.  We can get so busy it feels as if we barely have a chance to breathe.  However, we must!  If we take the time to constantly learn and pay attention, to really listen, it will make us all better, more well-rounded professionals, for the sake of our patients, staff, colleagues and, most importantly, even ourselves.