May 27, 2013

In the treatment field, it’s well known that patients relapse. Some patients need to go to treatment many times before they recover. ADAW asked leaders in the field to comment on this phenomenon and got a surprisingly diverse set of answers to the question: “What’s going wrong?”

Because addiction is a chronic disease, a relapse is not a treatment failure, according to the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

A. Thomas McLellan, Ph.D., CEO and co-founder of the Treatment Research Institute (TRI), said diabetes is a perfect example. He cited the massive Look AHEAD study funded by the National Institutes of Health that found that 40 percent of morbidly obese patients with hypertension and diabetes for whom insulin and other medications weren’t working were able to reverse their diabetes by walking 30 minutes a day and losing 15 pounds. “Radical lifestyle change is what they called it,” McLellan told ADAW. It was done with case managers, personal counselors, and family and patient support. “It sounds like recovery to me,” McLellan said.

Continuing management

While counseling an obese person to lose weight and exercise sounds like common sense, the medical system is structured around medication and surgery — or it used to be, said McLellan. The Affordable Care Act is changing that. “All of medicine is rethinking its approach to illness, especially chronic illness,” he said.

Meanwhile, in the substance use disorder (SUD) field, addiction was not originally recognized as a chronic illness, and there was little formal medicine or medications, he said. “We applied the tools we knew about — behavioral change through counseling, behavioral change in families, behavioral change in working with groups of peers who have the same illness.”

And in reality, although everyone pays lip service to the chronic disease notion, most treatment programs still treat it like an acute illness, said Phil Herschman, Ph.D., chief clinical officer for CRC Health Group. “We’re treating it like a broken leg, not like a chronic disease,” Relapse from page 1 he told ADAW. “You walk in the door for treatment and when you walk out the door, you should be abstinent and everything’s fine,” he said. “We measure you six months later, and you’re not fine.”

In diabetes, there are disease management concepts so that patients are monitored after an episode of care. “If they stopped their treatment, of course they’d have a treatment failure,” said Herschman. “With a chronic disease, there can’t be just an episode of care; there has to be lifestyle management.”

At CRC facility Sierra Tucson, a new experiment based on chronic disease management was launched this month. “This is a paradigm shift,” said Herschman. “Now when people get admitted, they’re not just coming in for a 30- or 35-day episode of care; they’re coming in for that and for one year of case management. We’re not providing treatment; we’re providing case management.” Each patient will be discharged with a continuing care plan that will include contacting the follow-up providers wherever the patient lives. Research shows that participating in this case management means patients are 90 percent more likely to be abstinent a year later, compared to a 40 percent chance if they do not, said Herschman.

If the Sierra Tucson experiment works, CRC will expand it to other programs. So far, the biggest problem has been convincing insurance companies to pay for it, said Herschman. “When I talk to the payers, especially the medical directors, nobody argues with the concept, but nobody understands how to pay for it yet,” he told ADAW. “When you think about healthcare reform, it’s really a push for this kind of treatment. Addiction is defined as a chronic disease, and the benefit that’s written into healthcare reform is an outpatient benefit.”

A menu of treatments

Raye Litten, Ph.D., associate director of the NIAAA Division of Treatment and Recovery Research, said that alcoholism isn’t a single disease, so there isn’t a single treatment that will work for everyone. “It’s a heterogeneous disease, and because of that we’re going to have to come up with a menu, or perhaps a combination,” he said. “To be honest, even if a treatment facility could use all of the medications that look promising, and had all the behavioral therapies that have shown effectiveness, there are still some people who wouldn’t respond.”

So far, there are four medications approved for the treatment of alcoholism: oral naltrexone, injectable naltrexone (Vivitrol), acamprosate and disulfiram. While these do not work for everyone, when they do work, “it’s dramatic,” said Litten. “It takes away craving and the urge to drink.”

An important area of NIAAA research for the next 10 years is “personalized medicine,” which enables clinicians to identify patients who will respond to certain types of treatment, said Litten. For example, Bankole Johnson, M.D., is looking at ondansetron, a now off-patent medication for the treatment of nausea, which certain alcoholics respond to based on their genetic variance, said Litten. Research is still in the early stages, but it appears that 34 percent of alcohol-dependent patients respond to ondansetron, Litten said.

Opposition to medications

Lack of medication use is an endemic problem in treatment programs; it was actually major news last year when Hazelden announced that it would start using buprenorphine — cautiously (see ADAW, November 12).

In fact, many treatment centers don’t use medications, and Burning Tree Recovery Ranch, which bases its reputation on treatment of hard cases including frequent relapsers, completely eschews them, and blames lack of spirituality and AA for the relapses.

“On a basic level, what I believe and what the treatment centers I work for believe is that most failures are a result of a client or an individual not having actually worked all 12 steps, and having a spiritual experience as a result of working all 12 steps,” said Heidi V. Smith, clinical director of the Kaufman, Texas-based program. “We believe that’s what’s missing, especially in the shorter-term programs where it’s impossible to complete all 12 steps.”

The Betty Ford Center doesn’t use medications either but does strongly support better training and long-term treatment. John Schwarzlose, CEO of the Betty Ford Center, attributes the problem to lack of trained staff. “Numerous programs, large and small, have unqualified staff working in important positions,” he said. “It is simply crazy, and who suffers is the alcoholic/addict and their loved ones seeking help.” The field needs to “raise the bar and clearly state what is required to be a frontline counselor,” he said. “How much education and training?” A physician working in a treatment center should be certified in addiction medicine, and nurses should be trained in addiction, he said. “Some of the best-known programs in the United States have hired their own patients within six to 18 months of sobriety to be counselors or technicians. This is unacceptable,” Schwarzlose said.

Lack of information

Litten sympathizes with the need to get better information out to patients about treatment options. “You can see the frustration,” he told ADAW. “One person called me who was a former state trooper, and said he couldn’t stop drinking, had tried AA and all sorts of things. I asked him if he tried naltrexone, and he didn’t know anything about it.” The man went to his physician, who told him he wouldn’t prescribe it because he didn’t think it would work. He called Litten back, who was outraged and told him he would find someone to prescribe it for him if necessary. “The man found someone and it worked — he called me saying he was a changed man,” said Litten.

McLellan related the story of a man who has spent at least $100,000 on five different treatments for his son, who is addicted to opioids. “The kid always did well while in treatment but relapsed in days to weeks after he got out,” said McLellan. The man — a university professor — had not heard of naltrexone, said McLellan. “Not one of those programs had told him about it,” he said.

If the son had had AIDS, the father would have known whom to call for information. “But he didn’t know where to get help for this,” said McLellan, noting that the man called him not because of some paper he had written, but because of the “strange underground of people who have lost their children to addiction.” (McLellan’s son Beau died of an overdose in 2009.) “I’m not saying he should have been on Vivitrol. I’m saying we have a lot of tools and we need a comprehensive approach by educated people so that a patient could actually get access to some of this treatment and get it applied under a chronic care approach,” he said.

McLellan said everyone’s responses to our question were “partly right.” And there were two areas that everyone completely agreed on, including McLellan: that the longer an episode of care is, the better a patient does, and that if insurance would reimburse SUD care management the way it reimburses diabetes care management, this model would be more likely to take hold. •