THE CHRONIC DISEASE MODEL IN THE TREATMENT OF ADDICTION!

The CDM Model Provides Successful Treatments in Addiction by Dr. Bouldin

The Chronic Disease Management Model (CDM) for addiction put forth by Dr. Richard Saitz and his colleagues view recovery as a continuous treatment process rather than a specified endpoint after a given treatment program. It is my firm belief, the CDM Model creators were correct with their insights as well as in their assessments of their meta analysis.

This approach has approach has found a place in my perception of addiction treatment as they had found within their observational perceptional found on and in between the lines of research. This common ideological perception they present is logical, valid, accurate and reproducible where the observations built a common thematic approach to treating addiction longitudinally. The CRM model is analogous to the diabetic blood glucose monitoring studies over twenty years ago and provides a ubiquitous framework to the future treatment, control and management of patients suffering with addiction. Dr Saitz has provided a logical scaffolding for which our perceptions of addiction may become more clear and understandable. I also concur this evolution is now becoming increasingly clear that addiction is in fact a disease like process found largely within our scope of mental health disorders and the similar pathological processes of other chronic diseases like diabetes, pulmonary conditions and heart disease. With the advent of the CDM, I find more understanding in the basis of addiction as well as the basis of the continual long term treatment plans which include the equally long recovery phases and relapse prevention programs. After reading the associated research articles I now find addiction as an ongoing processes where the treatments must be continued and managed for the successful treatment of substance use disorders.

In addition to stopping drug abuse, the goal of addiction treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain involved in long term treatment programs do in fact; stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning. For example, in the successful long term methadone treatment meta analysis, the methadone treatment has shown to increase participation in behavioral therapy and decrease both drug use and criminal behavior. Although not absolute, the individual treatment outcomes depend on the extent and nature of the patient’s problems and their perception of their problem as well as the appropriateness of their treatment and related services used to address their problems. Moreover, the quality of interaction between the patient and his or her treatment providers is most inclusive of the longitudinal treatment modalities.

Some people look at successful treatment in terms of relapse. Relapse rates for addiction resemble those of other chronic diseases such as diabetes, hypertension, and asthma. Like other chronic diseases, addiction can be managed successfully on a comprehensive continuous basis. It is shown in many cases that these programs enable people to counteract addiction’s powerful disruptive effects on the brain and subsequent behaviors with the end point recapturing control of their lives. The chronic nature of the disease means that relapsing to drug abuse is not only possible but also highly likely with symptom recurrence rates similar to those for other well characterized chronic medical illnesses such as; diabetes, hypertension, and asthma.

Unfortunately, when relapse occurs many deem treatment a failure. The prevailing opinion is, “This is not the case at all!” Successful treatment for addiction typically requires continual evaluation and ongoing modifications as seen appropriate. A similar approach is taken for other chronic diseases and have shown long term data in actual success rates for most chronic disease states. For example, when a patient is receiving active treatment for hypertension and their symptoms decrease then the treatment is deemed successful even though symptoms may recur when treatment is discontinued. The same can be said and in fact paralleled for the addicted individual. Relapses are now thought to be part of recovery by some and its occurrence does not indicate failure but rather progress. The progress comes with the acute flux in the treatment plan which will signify that treatment needs to be recalibrated, readjusted or that alternate treatment may be needed.

By definition in, The Case for Chronic Disease Management of Addiction, “Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care—elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure).”

It is logical to associate higher success rates when the CDM, chronic disease management model is implemented. One of the obvious components is the multidisciplinary team members approach utilizing nurse clinical care managers with disease-specific skills to coordinate referrals, communicate with clinical caregivers, and proactively follow patients; social workers to access community resources; and physician specialists. This effective matching of service to need is one goal of CDM and it is most useful addiction treatment practice. In addition to these common elements that address the issues and health, mental health and social problems, the CDM is specifically tailored for addiction frameworks which include individual addiction-specific interventions. One case identifies a patients problems, set goals, and change behavior based on internal motivation. Then multidisciplinary teams, including a nurse care manager, social worker and clinicians with expertise in the disease of interest, and expertise in common comorbidities can spend time with the patient and coordinate with primary care physicians, address necessary releases of information, and facilitate specialist referrals, provide access to community resources, implement evidence-based protocols, encourage self-management, and be proactive about follow-up. Information can be shared across team members, primary care clinicians, and specialists by using electronic records creating virtual colocation of care even when clinicians are in separate physical locations. This same information, when aggregated can and will support the attention of the team to the individual patients who have not received needed care and to clinical outcomes. In sum, an informed, motivated patient and a prepared, proactive team and delivery system lead to optimal chronic disease care and improved outcomes.

Because substance dependence is associated with significant medical illness and cost consequences, the evidence regarding CDM for medical illnesses also is relevant. Chronic disease management for heart failure, diabetes, arthritis and asthma, in randomized, controlled studies and in systematic reviews of more than 100 trials does in fact lead to clinical and functional improvement, decreased hospitalizations, treatment adherence, and patient satisfaction. Health systems adopting these programs report improved outcomes. Evidence for effectiveness of CDM for psychiatric and medical illnesses is strong. Because addiction has similarities with these chronic illnesses, CDM has potential for improving addiction outcomes. Intraorganizational interventions such as CDM have been proven feasible and effective and have now begun shaping the perceptions as well as forming the basis of the newly proposed model of CDM for addictions. Chronic disease management doe in fact improves patient adherence to treatments and disease control compared with the usual or standard care where it relies on patient education, reminders, and clinician education. Compared with usual standard of care the CDM interventions focus on a disease with concomitant attention to the comorbidities. I find this is a major strength and concrete promise of such intervention and it is a vast improvement in the disease model perception of addiction. As presented, Substance use, abuse and dependence is a common and costly chronic illness associated with medical and psychiatric comorbidity. Treatment can be efficacious when it is actually received by patients. But the current system of care is largely misunderstood and grossly fragmented. This poorly coordinated approach does not always include proven efficacious treatments in today's protocols. The CDM improves patient motivation and biopsychosoical issues which have all shown to stand alone as barriers to receipt of effective treatment. The CDM provides Integrated and coordinated care which simultaneously addresses patient motivation and the needs of cross sectional health domains. The research within the CDM by Dr Saitz model provides efficacious addiction treatments and facilitates effective access to other treatments. This integrated care may increase the likelihood that a higher level of care is noted and received by an addiction patient where the end point success is received and other clinical outcomes will improve downstream. The perception found within the nature of addiction is diverse. Whether viewing it as a chronic vs a nonchronic disease process is as individual, unique and specific to any one person even in cases of similar educational and psychosocial backgrounds. We as future providers all have our own preformed and neoforming perceptions feeding our perceived understanding of addiction which occurs regardless of our relativity to the disease itself. Would it not be safe to imply that given our tangential relationship with the disease of addiction, wouldnt our perceptions be much different to someone with no academic foundations? I Think the answer is obvious and logically. Furthermore, who is perception or definition is right or wrong, better or worse? By definition, perception is unique to all of us and the problem of perception as it pertains to addictions resides within all of us even in its rawest and most primitive forms. The arguments are endless and all worthy of conversations in my opinion as it is our fundamental biological process in being blessed with a frontal lobe. Moreover, is it not the state of nature for us a humans to create the very perceptions we are most affected by to provoke, to stimulate and ultimately to create effective change.

In the context of the CDM and the Chronic Disease State, it is hard for us to put into simple definition as it pertains to addiction. In order to build a similar architecture of the common perceptions of addictions, we as future counselors are able to tangentially remain relatively close in proximity when provided in similar exposure and background. It is inherent for us as humans to have very different and unique perspectives but as future healthcare providers in addiction the similarities are to our benefit. The CDM Model will is able to merge our perspectives that will ultimately drive our patients outcomes in a similar fashion especially if we adhere to our theoretical models found within the production of our future individualized treatment plans. It is up to us as forward thinkers to think logically and act appropriately within the confines of training we receive. If one person's perception of addiction is mal-aligned or misunderstood outside the theoretical constraints of a chronic vs a non chronic disease state, then success might be hard to achieve on a regular basis. I find that the very explanation of the CDM Model to a particular patient might serve to be a challenge within the individualized treatment plan and then again for some it may not. Furthermore, from a patients perception, would not the misunderstanding of their disease as chronic or non chronic be a misperception unto itself? This may be a proverbial, “chicken or the egg scenario” may be one of the many questions for the masses as it pertains to the enigmas of addiction. With that said, I do not perceive or think there is an exact right or wrong answer for the contrasted question, Disease vs Non Disease, but rather a willingness and openness of accepting all perceptions on both sides of this argument from both perceptions of treatment table whether good, bad or indifferent. In total, it is my sound belief that these similarities and differences will be the predecessors of our own evolving perceptions of addiction. With this natural process of constant flux, we will surely have a better ability to affect our patients expectations of their treatment success, their positive recovery outcomes, and ultimately the perception of their long term success milestones. References: 1-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2756688/ 2-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2756688/pdf/nihms-123835.pdf 3-http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/what-helps-people-stay-in-treatment 4-http://www.datos.org/publicationsJSAT03.html