Mind the Gap Between Treatment and Recovery
More than half of all Medicaid patients in New York do not receive follow-up care after rehab or detox.
While it is becoming more common that substance use disorders are recognized as a disease requiring medical treatment, the fact that it is a chronic disease requiring ongoing care is not yet reflected in widely available treatment models.
“Treatment alone is not enough for people dealing with addiction” said Arlene González-Sánchez, Commissioner of the Office of Alcoholism and Substance Abuse Services, “and we need to make sure that the proper recovery supports are available.”
For patients on Medicaid, New York state data from the Behavioral Health Office from 2011 to 2014, the most recent reports available, shows that half or more of those patients discharged from acute treatment (such as detoxes or rehabs) did not receive follow-up care within 14 days.
A lack of continued treatment, including medical, social and psychological support, is ultimately costly for the state: regions with the lowest levels of continuity of care have strikingly higher levels of readmissions to intensive care settings.
According to the principles of effective treatment created by the National Institute on Drug Abuse,“Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment.”
The guidelines also note that individuals tend to leave treatment prematurely, making efforts to engage patients longterm especially important. Engaged care is defined by the Behavioral Health Office as receiving at least two instances of lower-intensity follow-up treatment within the first 14 days out of a detox or rehab center.
“Remaining in treatment for an adequate period of time is critical.” — National Institute on Drug Abuse
The correlation between regions with low patient engagement after detox or rehab, and high rates of readmission to acute care, which includes emergency rooms, supports research showing that relapse is highly likely in the period immediately after leaving treatment. Relapse rates within the first year after detox are as high as 88 percent for opioids, according to this study from the Journal of Addiction, and 60 percent for methamphetamine use. Rates of relapse for alcohol abuse are between 50–90 percent in the first four years after rehab, according to the National Institute on Drug Abuse.
Deaths from opioids and alcohol are especially likely during a relapse directly following treatment, since patients no longer have a tolerance for the substances. The risk of death from an overdose due to decreased tolerance is higher with opioids in particular because of their depressive effects on the respiratory system.
One study from the National Institute for Health Research in the U.K. found rates of overdose after leaving treatment to be three times higher than the researchers had expected. The study authors noted:
“The clustering of the deaths from overdose in the group of patients who had successfully completed treatment is counterintuitive and illogical — unless it derives from loss of tolerance and consequent unpredictability of resumed heroin use.”
Stephen Higgins, a professor of psychiatry at the University of Vermont noted in an interview with USA News that proven methods for keeping people engaged in longer-term treatment have largely been ignored by policy-makers.
“The failure to act allows these people to overdose. … That shouldn’t happen, and it’s not acceptable,” he said.
His research has focused on contingency management plans, which reward people for abstinence as opposed to punishing people for using. Contingency management, along with what his team calls community reinforcement — which aims to reorient a person’s life towards stable housing, employment and hobbies — has consistently produced the best results in studies.
