PAC 320 Module 4 Outpatient Treatment Example

From Graduation to Ongoing Care: Redesigning an Outpatient Program Around the Evidence That Addiction Behaves Like a Chronic Illness

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 320: Psychology of Addiction

Instructor Name

Month Day, Year

From Graduation to Ongoing Care: Redesigning an Outpatient Program Around the Evidence That Addiction Behaves Like a Chronic Illness

Cedar Hill Recovery Center's outpatient program, at the invented Asheville center in these papers, runs for twelve weeks: three evenings a week of group counseling and one individual session. Clients who complete it attend a graduation ceremony, receive a certificate and are discharged. The ceremony is moving, and staff are proud of it. But a review of last year's graduates found that forty-two percent were readmitted to Cedar Hill within twelve months, and staff suspected that others had relapsed without returning. The clinical director asked whether the program's design matched what is known about addiction. This paper argues that it does not and proposes a redesign. The center and its readmission figures are invented, though the research behind the redesign is real.

Addiction as a Chronic Illness

McLellan et al. (2000) compared drug dependence with three chronic medical illnesses: type 2 diabetes, hypertension and asthma. They found striking similarities. All four conditions have substantial genetic contributions. All involve personal choices in their onset, such as diet, exercise or drug use, and in their management. Adherence to treatment is a problem in all four: many patients with hypertension or asthma do not take medications as prescribed, just as many people with addiction do not complete treatment. And relapse rates are similar: a substantial share of people treated for addiction relapse within a year, comparable to the share of patients with hypertension or asthma whose symptoms recur and require additional care. The authors argued that addiction should be treated, insured and evaluated like other chronic illnesses, with ongoing management rather than a single episode of care.

The implication for Cedar Hill is direct. No one would graduate a patient from hypertension care after twelve weeks and discontinue follow-up. The program's design treats addiction as an acute condition that ends with discharge.

Medication and Counseling in Outpatient Care

For alcohol use disorder, the most common diagnosis in Cedar Hill's outpatient program, evidence supports offering medication alongside counseling. In the COMBINE trial, Anton et al. (2006) randomly assigned nearly fourteen hundred recently abstinent adults with alcohol dependence to combinations of naltrexone, acamprosate or placebo, with medical management, a brief supportive approach delivered by health professionals, and with or without a more intensive combined behavioral intervention delivered by specialists. Patients who received naltrexone with medical management, or the combined behavioral intervention with medical management and placebo, had better drinking outcomes than those who received placebo with medical management alone. Combining naltrexone with the behavioral intervention did not add further benefit, and acamprosate showed no benefit in this trial. The authors noted that naltrexone with medical management could be delivered in primary care settings.

Cedar Hill currently offers no medications in its outpatient program. Many clients with alcohol use disorder could benefit from naltrexone, and clients with opioid use disorder from buprenorphine.

Continuing Care

McKay (2005) reviewed controlled studies of continuing care interventions, defined as care that extends beyond an initial episode of treatment. About half of the studies found that continuing care improved outcomes. The interventions most likely to work were those lasting longer, generally a year or more, and those that made active efforts to reach clients, such as telephone contact and outreach, rather than relying on clients to return. McKay concluded that extended, low-intensity, actively delivered continuing care was a promising approach for disorders that often follow a chronic course.

The Redesign

What Clients Said

Before finalizing the redesign, staff called twenty recent graduates. Several said that the week after graduation was the hardest of their recovery, because the structure they had relied on disappeared overnight. Others said they would have come back sooner after a slip if returning had not meant a new intake and a waiting list. One said simply that the ceremony made her feel finished when she was not. Their accounts matched the research: the transition out of intensive care is a period of high risk, and barriers to returning delay help when it is most needed. The redesign's step-down schedule and rapid readmission respond directly to what graduates described, and two graduates agreed to help lead the new monthly group.

Why Medication Was Missing

Cedar Hill's outpatient program had never offered medication, partly because of its history as an abstinence-based program and partly because it had no prescriber. Some longtime staff worried that naltrexone or buprenorphine would send clients the wrong message. The COMBINE findings, and the broader evidence for buprenorphine in opioid use disorder, suggest that withholding medication sends a worse one: that the program values its traditions over its clients' outcomes. The redesign treats medication as an option offered to every eligible client, with counseling continuing for all.

Implementation and Costs

The redesign adds a part-time prescriber, a care coordinator for phone checkups and outreach and staff time for monthly groups. Costs can be offset partly by billing for continuing care and medication management and partly by fewer readmissions to more expensive intensive care. The ceremony will continue, renamed and reframed, because recognizing clients' achievements remains valuable.

Evaluation

Cedar Hill will compare the eighteen months after the redesign with the year before. Measures will include readmission to intensive care, the percentage of clients reached by phone each month, medication uptake and, through brief phone surveys, days abstinent and quality of life at six and twelve months.

Conclusion

Cedar Hill's twelve-week program ends with a ceremony that fits an acute illness, and its readmission rate suggests the design misreads addiction's course. McLellan and colleagues show that addiction resembles other chronic illnesses, the COMBINE trial shows that medication with medical management or a combined behavioral intervention improves outcomes and McKay shows that extended, active continuing care helps. Redesigned around these findings, the outpatient program would treat its graduates as patients whose care continues.

References

Anton, R. F., O'Malley, S. S., Ciraulo, D. A., Cisler, R. A., Couper, D., Donovan, D. M., Gastfriend, D. R., Hosking, J. D., Johnson, B. A., LoCastro, J. S., Longabaugh, R., Mason, B. J., Mattson, M. E., Miller, W. R., Pettinati, H. M., Randall, C. L., Swift, R., Weiss, R. D., Williams, L. D., & Zweben, A. (2006). Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. JAMA, 295(17), 2003-2017. https://doi.org/10.1001/jama.295.17.2003

McKay, J. R. (2005). Is there a case for extended interventions for alcohol and drug use disorders? Addiction, 100(11), 1594-1610. https://doi.org/10.1111/j.1360-0443.2005.01208.x

McLellan, A. T., Lewis, D. C., O'Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA, 284(13), 1689-1695. https://doi.org/10.1001/jama.284.13.1689