Substance Abuse Treatment Needs Overhaul

I read with much interest the articles in the December 3, 2010, issue regarding substance abuse treatment. I am a psychiatrist and addictionologist in a solo private practice and have been the medical director of a traditional 28-day inpatient treatment program, as well as the director of a hospital-based, dual-diagnosis program.

There are many issues that were addressed in the articles, including the reluctance of many addicted patients to seek treatment, insurance limitations on treatment, high relapse rates, and the need to consider the six dimensions of assessment as outlined by Dr. David Mee-Lee. I want to offer my observations and concerns about these issues based on years of experience with patients and their families in various treatment settings.

I feel strongly that there are two key issues that must be addressed to improve service delivery and enhance treatment outcomes.

First, it is imperative that recent advances in the understanding of neural reward pathways be considered. Too often a patient presenting to a specified level of care, from intensive outpatient to residential inpatient rehabilitation, is plugged into a "one size fits all" treatment program. For example, a patient with opiate dependence admitted to detox/rehab invariably will be detoxed over several days with the intent of having the patient drug and alcohol free and not receiving any medication by the time of discharge.

However, a patient who has already had this treatment experience, often having been detoxed several times, still receives the same treatment approach because this is what the treatment program believes in. Alternatively, if a comprehensive assessment was done on admission, it might suggest that a far better alternative, given the patient's repeated failures, would be medication-assisted treatment (MAT) using buprenorphine maintenance.

It is astounding to me that the overwhelming majority of treatment programs do not recognize that a patient's past treatment failures necessitate consideration of alternative treatments, especially in light of advances in brain science and medication development that have led to clinically proven and evidence-based medications to assist the patient in maintaining sobriety. When will the addiction treatment field finally catch up to scientific advances that include MAT as an important option?

Though I am not trying to defend insurance company policies, perhaps the insurance industry can pressure treatment programs to consider alternatives, including medication-assisted recovery, that outcome studies are showing to be superior to "traditional" detox and rehab programs.

My second concern is how treatment programs are structured. It is the rare program that offers comprehensive, integrated treatment along the continuum from inpatient to outpatient care. Patients are transitioned from inpatient care to intensive outpatient care but rarely have the same psychiatrist, nurse, social worker, or addiction counselor that they had during their initial treatment experience. While a copy of their discharge summary may accompany them, much is lost when the treatment alliance and trust built during the initial treatment experience ends and needs to be replaced by another treatment team. Valuable therapeutic work on family issues, relapse concerns, and past trauma experiences is abruptly ended when the patient transitions to another system of care with different clinical staff.

It is highly preferable for a program to offer all levels of care, with the clinical staff "following" the patient as he or she moves from higher to lower levels of care (or sometimes vice versa). The same counselor, social worker, and psychiatrist continue with the patient along the care continuum.

Unfortunately, most inpatient addiction programs are limited in their ability to do this, especially those located in rural areas that are far from the population centers their patients often come from. I am convinced that an integrated continuum-of-care approach would greatly improve treatment outcomes and improve on the high rate of treatment failures and relapses.

As patients experience early recovery success, it is imperative that they connect with treatment professionals who will be there for them when they experience setbacks in the various biopsychosocial dimensions that Dr. Mee-Lee describes. Being trusted by and known to the patient improves the likelihood that the patient will reach out to the clinicians involved in his or her care when biomedical, behavioral/emotional, readiness, and relapse issues arise.

Ending this treatment relationship after the 28 days of inpatient treatment and starting with a whole new set of clinicians is not in the patient's best interest and should not be the standard of care in addiction treatment.