The Case for Chronic Disease Management for Addiction

Abstract

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 model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. 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), CDM has been proven effective. Keywordschronic disease management; addiction; primary care; linkage; addiction treatment; chronic care model; recovery Substance (alcohol and drug) dependence is a chronic disease for which many affected adults receive no intervention or detoxification without subsequent treatment. Like other chronic diseases (eg, diabetes, congestive heart failure), substance dependence has no cure and is characterized by relapses requiring longitudinal care. Medical and psychiatric comorbidities are the rule rather than the exception. As a result, care delivery can be complex both for clinicians and patients. In the United States, systems of care for substance dependence (both alcohol and drug) are rarely integrated with those for medical and psychiatric illnesses. Specialty alcohol and drug treatment is efficacious, but many patients do not access available treatment for substance dependence problems after detoxification or medical care. Others enter NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript specialty addiction treatment but do not receive medical or psychiatric care. Some have called to expand the frame of health services research on addictions to include services outside the specialty treatment sector, including behavioral care integrated into primary care. [1][2][3] Although primary care settings provide the venue for longitudinal, comprehensive, and coordinated care, their potential to effectively treat addiction and related comorbidities has not been realized; medical, mental health, and addiction treatment are not coordinated. Primary care settings, with reorganization and appropriate service elements, hold the promise of simultaneously improving physical and psychiatric health while decreasing substan...

Now is the Time to Address Substance Use Disorders in Primary Care

“…Fortunately, the rise in care management and co-located behavioral health in patient-centered medical homes can provide the organizational infrastructure that can be responsive to effective treatment. 25,26 The essays by Lathrop and Gastala give voice, in different ways, to the physician perspective on engaging and caring for patients who have substance use disorders. Lathrop notes the changing roles and expectations of physicians, particularly around grief and burnout.…”

“…30 We need to expand the framework of chronic care management to include substance use disorders and other mental health conditions under the same roof as congestive heart failure and other chronic conditions. 25,26 Attention to mental health, in the context of being accountable for the care of populations (eg, accountable care organizations), should be expanded and implemented to manage people who also have addiction. 26 The treatment of opioid use disorder in primary care has efficacy and is feasible, and published clinical experiences, such as those in this issue of Annals, are adding to the information base.…”

Performance contracting to engage detoxification-only patients into continued rehabilitation

“…First, although much has been written about the need to create a continuum of care for addiction treatment services (Carroll, Triplett, & Mondimore, 2009;McLellan, 2002;Saitz, Larson, LaBelle, Richardson, & Samet, 2008;Simpson, 2004), to our knowledge, Delaware is the first state to employ financial contingencies to increase the number of detoxification patients directly entering treatment. Importantly, the contract was initiated after other attempts to improve provider's performance had stalled.…”

Enhancing Transitions from Addiction Treatment to Primary Care

“…12 Treatment for SUDs may benefit from a similar approach as that recommended for chronic medical disorders: specialty care when the condition is severe, followed by the provision of services in primary care that are oriented toward the long-term management of SUDs when the condition is stabilized. 15,16 In the case of SUDs, management may need to be more intensive and of longer duration. 17 Despite now long-standing recommendations that enhanced efforts should be made to link SUD patients to primary care, 9 to the authors' knowledge, no conceptual models exist that help AT providers select among evidencebased strategies to promote patients' use of primary care after discharge from or completion of the acute phase of AT.…”