William L. White1 and John F. Kelly
(1)
Lighthouse Institute, Chestnut Health Systems, Bloomington, IL, USA
William L. White
Email: bwhite@chestnut.org
Abstract
Today, almost 14,000 specialized addiction programs treat approximately two million individuals a year in the United States. This treatment spans a wide diversity of settings, levels of care, service philosophies, and techniques. However, most share an acute-care model of intervention, characterized by a single episode of self-contained and unlinked intervention focused on symptom reduction and delivered within a short timeframe. Impressions are given that long-term recovery should be achievable following such acute intervention. This model is now being challenged, and calls are increasing to extend the design of addiction treatment to a model of sustained recovery management that is comparable to how other chronic primary health disorders are effectively managed. Recovery management is a philosophy of organizing treatment and recovery supports to enhance early engagement, recovery initiation and maintenance, and the quality of personal/family life in the long-term. This chapter provides an overview of this book highlighting the theory, science, and practice of recovery management and exploring how it is being incorporated into larger “systems transformation” processes. This is the first academic text designed specifically to focus on recovery management as a philosophy of professional treatment and a framework for recovery management.
Keywords
Addiction treatment modelsAcute-careRecovery managementSystems of careChronic illness
Introduction
An elaborate system of inebriate homes and asylums, private addiction cure institutes, religiously sponsored missions and inebriate colonies, and bottled and boxed “home cures” for alcohol and drug addiction flourished in the United Sates during the mid-nineteenth century only to collapse in the opening decades of the twentieth century [1]. A new generation of addiction treatment and recovery advocates coalesced in the mid-twentieth century to lay the foundation for the resurrection of modern addiction treatment. What began as two social movements (one focused on alcoholism and the other focused on narcotic addiction and rising youthful “polydrug abuse”) were subsequently integrated, professionalized, commercialized, and supported by federal, state, and local governments, as well as private systems of health-care reimbursement. Today, almost 14,000 specialized addiction programs treat approximately two million individuals a year at an annual cost in the range of 11 billion dollars [2, 3]. This treatment spans a wide diversity of institutional settings, levels of care, service philosophies, and service techniques which are collectively supported by administrative, management, regulatory, education, training, and research infrastructures that have become industries in their own right.
References to these thousands of direct service and support institutions as a specialized “system of care”, however, grossly misrepresent their level of integration or even coordination. Yet, most of these programs do have something in common; they share an acute-care (AC) model of intervention that has dominated specialized addiction treatment. White and McLellan [4] define this model in terms of seven core characteristics:
· Services are delivered “programmatically” in a uniform series of encapsulated activities (screening, admission, a single-point-in-time assessment, a short course of minimally individualized treatment, discharge, and brief “aftercare” followed by termination of the service relationship).
· The intervention is focused on symptom elimination for a single primary problem.
· Professional experts direct and dominate the assessment, treatment planning, and service delivery decision making.
· Services transpire over a short (and historically ever-shorter) period of time – usually as a function of a prearranged, time-limited insurance payment designed specifically for addiction disorders and “carved out” from general medical insurance.
· The individual/family/community is given the impression at discharge (“graduation”) that “cure has occurred”: long-term recovery is viewed as personally self-sustainable without ongoing professional assistance.
· The intervention is evaluated at a short-term, single-point-in-time follow-up that compares pretreatment status with discharge status and posttreatment status, months – or at best a few years – following professional intervention.
· Posttreatment relapse and readmission are viewed as the failure (noncompliance) of the individual rather than possible flaws in the design or execution of the treatment protocol.
That acute-care model is now being challenged. There is a revolution underway in the design and delivery of addiction treatment in the United States. That revolution promises to change how severe alcohol and other drug (AOD) problems and the people experiencing such problems are viewed and treated.
The impetus for such change comes from multiple sources. A new recovery advocacy movement is calling for addiction treatment to become reconnected to the larger and more enduring process of personal and family recovery [5]. Frontline practitioners lament working in addiction treatment institutions that seem to care more about margin (financial profit and regulatory compliance) than mission (recovery outcomes) – more about a progress note signed by the right color of ink than whether those being served are actually making progress [6]. Research critiques of addiction treatment from within the field are calling for a “fundamental shift in thinking” [7], a “paradigm shift” [8], a “seismic shift rather than a mere tinkering” [9], and a “sea change in the culture of addiction service delivery” [10]. Administrative, regulatory, and funding authorities are calling for a redesign of addiction treatment in response to a growing population of individuals repeatedly recycling through addiction treatment at great cost with no measurable long-term recovery outcomes. After two decades of hearing the treatment industry’s central mantra, “Treatment Works,” most know someone for whom addiction treatment did not work and the public at large has grown weary of the rich and famous regularly cycling into “rehab.” Addiction treatment’s probationary status as a social institution is set to be severely tested.
Within this cultural and professional context, calls are increasing to extend the design of addiction treatment from a model of acute biopsychosocial stabilization to a model of sustained recovery management that is comparable to how other chronic primary health disorders are effectively managed.
Recovery management is a philosophy of organizing addiction treatment and recovery support services to enhance early prerecovery engagement, recovery initiation, long-term recovery maintenance, and the quality of personal/family life in long-term recovery [11].
There are simultaneous calls to embrace these recovery management philosophies within larger recovery-oriented systems of care.
Recovery-oriented systems of care are networks of indigenous and professional support designed to initiate, sustain, and enhance the quality of long-term addiction recovery for individuals and families and to create values and policies in the larger cultural and policy environment that are supportive of these recovery processes. The “system” in this phrase is not a federal, state, or local agency, but a macro-level organization of the larger cultural and community environment in which long-term recovery is nested [11].
The purpose of this book is to provide a primer on the theory, science, and practice of recovery management and to explore how recovery management is being incorporated into larger behavioral health “systems transformation” processes. This movement has until now been chronicled only on the pages of scientific journals and government monographs, through papers posted on recovery advocacy web sites (e.g., Faces and Voices of Recovery) and through presentations at professional conferences. This is the first academic text designed specifically to explore recovery management as a philosophy of professional treatment and a framework for recovery self-management.
Part I includes several chapters that cover seven foundational premises of recovery management:
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5.
6.
7.
Part II summarizes scientific studies that support the movement toward sustained recovery management. Christy Scott and Michael Dennis highlight the results of a series of experiments utilizing posttreatment recovery checkups with adults as a strategy of long-term recovery support. The chapters by Sandra Brown and colleagues, and Mark Godley, review the research that has been conducted on long-term recovery trajectories of adolescents followed up across the high-risk substance use period of emerging adulthood and that provides evidence for assertive linkage approaches to posttreatment continuing care for adolescents. In the concluding chapters in Part II, Leonard Jason and colleagues note the emergence of new recovery support institutions and review the studies his research group has conducted on the growing network of Oxford Houses in the United States, and James McKay summarizes the outcomes of the scientific studies that have been conducted to evaluate the effects of continuing care interventions for adults.
Part III moves from the theoretical conceptualization and research studies related to recovery management to the real-world efforts to implement recovery management and recovery-oriented systems of care. In Chaps. 11 and 12, Kirk and Achara-Abrahams and colleagues describe the recovery-focused systems transformation effort each has led, respectively, in the State of Connecticut and the City of Philadelphia. In Chap. 13, Boyle describes the rationale, methods, and outcomes linked to the implementation of a recovery management philosophy within a local behavioral health-care organization in Peoria, Illinois. In Chap. 14, Valentine describes the peer-based recovery support services piloted within the Connecticut Community of Addiction Recovery – a grassroots recovery advocacy and support organization. In the final chapter in Part II, DuPont and Skipper describe the Physician Health Program (PHP) as a model of extended recovery management that has generated the highest recovery rates in the scientific literature. They suggest that major elements of the PHP could be adapted for mass application to addiction treatment programs throughout the United States.
Part IV contains a final chapter in which Kelly and White discuss recovery management and the future of addiction treatment. They draw six key conclusions:
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2.
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The future of addiction treatment as a social institution may rest with its ability or inability to move toward treatment of addiction via a model of sustained recovery management.
In closing this introduction, we would like to acknowledge and thank all of the authors who contributed to this volume. Their collective efforts have exerted an enormous influence on the evolution of modern addiction treatment and recovery. We would also like to thank Julie Yeterian, Sarah Dow, and Julie Sloane for their help in the preparation of this volume.
References
1.
White W. Slaying the dragon: the history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems; 1998.
2.
Mark TL, Levit KR, Coffey RM, et al. National expenditures for mental health services and substance abuse treatment, 1993–2003 SAMHSA Publication No. SMA 07-4227. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2007.
3.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The ADSS cost study: costs of substance abuse treatment in the specialty sector, analytic series A-20, DHHS Publication No. (SMA) 03-3762. Rockville, MD; 2003.
4.
White W, McLellan AT. Addiction as a chronic disease: key messages for clients, families and referral sources. Counselor. 2008;9(3):24–33.
5.
White W. Let’s go make some history: chronicles of the new addiction recovery advocacy movement. Washington, DC: Johnson Institute and Faces and Voices of Recovery; 2006.
6.
White W. The treatment renewal movement. Counselor. 2002;3(1):59–61.
7.
Moos RH. Addictive disorders in context: principles and puzzles of effective treatment and recovery. Psychol Addict Behav. 2003;17:3–12.PubMedCrossRef
8.
Dennis ML, Scott CK, Funk R, Foss MA. The duration and correlates of addiction and treatment careers. J Subst Abuse Treat. 2005;28 Suppl 1:S51–62.PubMedCrossRef
9.
Humphreys K. Closing remarks: swimming to the horizon – reflections on a special series. Addiction. 2006;101:1238–40.PubMedCrossRef
10.
Miller WR. Bring addiction treatment out of the closet. Addiction. 2007;102:863–9.CrossRef
11.
White W. Recovery management and recovery-oriented systems of care: scientific rationale and promising practices. Pittsburgh, PA: Northeast Addiction Technology Transfer Center, Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health & Mental Retardation Services; 2008.
12.
Granfield R, Cloud W. Coming clean: overcoming addiction without treatment. New York: New York University Press; 1999.
13.
Dennis ML, Scott CK. Managing addiction as a chronic condition. Addict Sci Clin Pract. 2007;4(1):45–55.PubMedCrossRef
14.
McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. J Am Med Assoc. 2000;284(13):1689–95.CrossRef
15.
Scott CK, Foss MA, Dennis ML. Pathways in the relapse – treatment – recovery cycle over 3 years. J Subst Abuse Treat. 2005;28 Suppl 1:S63–72.PubMedCrossRef
Footnotes
1
Recovery capital encompasses the quantity and quality of internal and external resources that can be mobilized to initiate and sustain recovery from addiction [12].