TreaTmenT models
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A model
of choice
It’s time for a paradigm shift in our
view of addiction, says Dr Julia Lewis
TRENDS COME AND GO and nowhere more
so than in the shifting world of addiction
management. The pendulum seems to swing
from one paradigm to another with the
supporters of each frequently baying for the blood
of their opponents. Some support abstinence as
the only sensible goal, and berate the so-called
‘medical model’ with its alleged transfer of
dependence to state-endorsed substances, while
others shout loudly in support of what they claim
is a more inclusive harm reduction approach.
But what if there was a model that
encompassed all these laudable ideas and then
took things a stage further?
In 2007 the World Health Organization
called the management of chronic disease
(such as asthma, diabetes and hypertension)
‘one of the greatest challenges facing
healthcare systems throughout the world’. Out
of these concerns developed the chronic
disease management (CDM) Model defined by
the Disease Management Association of
America as ‘a system of coordinated healthcare
interventions and communications for
populations with conditions in which patient
self-care efforts are significant’.
Various researchers have argued that this
model can be applied to the management of
addiction, as evidence suggests that addiction has
a similar profile to other chronic diseases. For
instance, more than half of patients entering
publicly funded addiction services in the USA
achieve and sustain recovery after multiple
episodes of treatment over several years, and
addiction is associated with chronic physiological
changes; a relapsing, remitting course; comorbidity; a need for ongoing care but with variable
adherence to that care; and the absence of a ‘cure’.
Current models of addiction treatment
provision in the UK frequently follow an acute care
model, concentrating on the management of
complications of use as opposed to the underlying
condition, and lacking essential coordination of
care across health and social care systems.
However, managing addiction solely through
these acute episodes of brief stabilisation and
detoxification can contribute to the frustration of
service users, their families and the public
regarding prospects for permanent recovery.
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Also, as a chronic disease with biological,
genetic and physiological elements, addiction
should be addressed via a case-managed
combination of treatment modalities,
personalised to the assessed needs of the
service user, providing an integrated
pharmacopsychosocial approach to treatment.
In contrast, the CDM model bases care on the
service user’s needs, values and decisions, rather
than reacting to problems. Nevertheless,
transferring the CDM approach to the
management of addiction requires a move into
a recovery-oriented system and the recovery
management (RM) model has been developed to
combine these two treatment paradigms.
So, what are the essential features of an RM
model of addiction treatment?
The model is easy to access and geared to
developing motivation. The care planning process
focuses on the whole life of the service user, not
just the problems caused by their use, and
supports their right to manage their own
condition. The clinician is seen as an educator,
providing long-term support, and a comprehensive care plan brings together services best placed
to address their needs. Interventions are evidencebased and include all relevant modalities, and the
emphasis going forward is on self-management,
with links to recovery resources in the community
and easy access to re-intervention if needed.
It is possible that the RM model provides us
with an integr