We are in the midst of the largest opiate epidemic in the history of our nation. According to the Centers for Disease Control, drug overdose deaths are now the leading cause of death from injury in the United States, and each day almost 7,000 people are treated in emergency departments for using drugs in a manner other than as directed. Costs associated with substance use disorders (SUDs) total upwards of $200 billion a year.
It is worth noting substance use disorders are a medical condition, and just like with any other medical condition, delayed care or services provided in a compromised way will significantly diminish the effectiveness of treatment, and exacerbates the mistaken public perception that treatment does not work. It does.
For recovery to take hold, it is imperative for a person to get the proper intensity and duration of care provided in a comprehensive and timely manner. This is what we would want for anybody seeking help for any condition that is likely to result in death if untreated. Nothing should be different because the condition we are talking about is a substance use disorder. Failure to provide the proper elements of care can lead to a return to active drug use for the client, and all of the devastating issues associated with substance use disorders, up to and including loss of life.
According to the National Institutes on Drug Abuse for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommended for maintaining positive outcomes. People often receive far less than that, and we typically engage people in care at a late stage of the condition. Early intervention is particularly important with Substance Use Disorders, but we have a long way to go before such services become widespread and easily accessible at an early stage in the United States.
As an analogy, what we do with substance use treatment is like treating an infection that would require a 10-day course of antibiotics with a three-day dose and hoping for a positive outcome, often at a later stage of the condition. While this has worked for many, we can and should do far better. There is significant room for improvement in the manner, intensity and duration of care.
Impaired professional programs
In comparisons to services available to the general population, when a physician, airline pilot, pharmacist or nurse experiences a substance use disorder, they are typically placed in impaired professional programs. These programs provide services of greater intensity and duration than those offered the general public. Additionally, they offer long term case management components and random urine testing for years after the sentinel event in order to ensure that they are getting better. Services typically last between three and five years and are monitored very closely over the years of engagement – much like a cancer patient gets regular checkups for up to five years in order to ensure that the person is still in remission. A number of studies have been done on these kinds of programs, and they show an efficacy rate for long term success of around 75% to 80% – markedly higher than the short term, lower intensity programs offered within nearly all healthcare plans.
Another way to look at this is to that the short term programs typically offered through insurance bears little relationship between the longer-term programming that the research shows is most effective. The “gold standard” programs such as those provided to impaired professionals are simply not available to the general public. Can we think of any other medical condition in which the kinds of services that are most likely to succeed are not offered to most people?
Medication Assisted Therapy (MAT)
Medications, such as methadone, vivitrol and buprenorphine can be important and lifesaving elements in the treatment and recovery process for many people. Like any medication, there are risks, and like with most medical conditions, medications must be combined with therapeutic interventions to be effective. There is some growing concern that we are not ensuring that therapy is being combined with the medications in order to have an effective intervention. We know that the research has shown that failure to combine these pharmaceutical interventions with therapy greatly reduces the efficacy of the intervention. We need to make sure that medications are used with a comprehensive service plan in order to realize their full benefits.
When considering the effectiveness of treatment, central to effective treatment is the therapeutic alliance– the bond between the client and the therapistor helping professional. It is the means by which a therapist and a client work to engage with each other and effect beneficial change in the client. The emerging picture suggests that the quality of the client–therapist alliance is a reliable predictor of positive clinical outcome, independent of psychotherapy approach or outcome measures. This powerful finding suggests that strengthening of skill sets around client engagement can be a very effective way to improve client outcomes:
- A critical ingredient of a therapeutic alliance includes empathy, or the ability to identify with the feelings of the client.
- Another element of this alliance is expertise; the client must sense that the therapist possesses the skills to help.
- Hopeis also an important ingredient, as there must be an underlying belief that change will happen.
- Finally, effective therapeutic alliances are strength-based; they emphasize the internal and external resources of the client within the treatment over any barriers that they face.
Comprehensive services and supports
Services that augment traditional therapy can greatly assist the person in coming to terms with their substance dependence and rebuilding their lives; these can include medical, psychiatric, nutritional, peer, familial and family services. Comprehensive care plans holistically address the impact of the use on the life of that person and those around him or her, while assisting the person in developing new coping skills and resources. Close case management and consistent follow-up are critically important for sustained recovery, particularly as the person transitions between levels of care or faces new challenges in the early recovery process.
Changing the environment of recovery in our communities
Beyond the traditional treatment system, an emerging trend is the rise of community-based organizations developed for and by people in recovery. Called Recovery Community Organizations (RCOs), these organizations provide anchor points within our communities. There is growing recognition that such centers have an important place in assisting persons to develop and sustain recovery in their own communities.
For our younger people, recovery high schools and collegiate recovery programs are being opened around the country, so they can go to school and socialize with people in their age groups. The goal of these services is to provide an environment to nurture the recovery process and forge the recovery life pathway. We know that when we can assist young people early on in sustaining recovery, the more likely they will stay in recovery for life.
The use of peer services
We have also seen the emergence of peer services which are non-clinical and provided by people with lived experience, often through peer providers, RCOs, treatment agencies, and the faith community. Recovery support services restore hope and help people enter into and navigate systems of care, remove barriers to recovery, stay engaged in the recovery process, and live full lives.
Substance Use Disorders impact one in four U.S. families, and every one of us is affected by the impact of untreated substance use disorders. The good news is that today more than 23 million Americans are in long term recovery, and we can expand this number, which will pay dividends in saved lives, resources and healthier communities. We know what works, and we need increased awareness and coordinated advocacy efforts to move our systems in this direction.