“New Paradigm” Addiction Recovery Model Takes Long-Term View

People in recovery from substance use disorders who have had repeated relapses can benefit from being monitored for at least five years after treatment, according to a former head of the National Institute on Drug Abuse.

“Addiction is life-long and treatment is brief,” says Robert DuPont, M.D., President of the Institute of Behavior and Health. “We need to shift our thinking about treatment from the current focus on short-term episodes to long-term recovery management. That should include frequent random drug testing for alcohol or drug use, with serious consequences for failing. That is the lesson from state Physician Health Programs (PHP), which set the standard for good long-term outcomes from substance use disorders.”

He described the model for such care, called the New Paradigm for Recovery, at a recent meeting of the CORE (Clinical Overview of the Recovery Experience) conference. The New Paradigm is not a new treatment program. It is a system of long-term care management for substance use disorders that enhances and extends the benefits of all treatment programs.

Currently, formal episodes of substance use disorder treatment are relatively brief, even though addiction is a life-long disorder.  In a recent report, the institute stated the median length of stay of a person who completed treatment in 2008 ranged from four days for detoxification, to 124 days for outpatient treatment and 197 days for outpatient medication-assisted opioid therapy.  “Whether or not an episode of treatment is completed, the large majority relapses to alcohol and drug use,” the report noted.  “Relapse after episodes of treatment is so common that it is often defined as a central element of this chronic disorder.”

The model for the New Paradigm is the Physician Health Program (PHP), which helps addicted doctors get the drug, alcohol and mental health treatment they need to keep their licenses and return to practice. If a doctor in the program uses alcohol or drugs even once, the consequences are swift and serious. They are pulled out of practice, evaluated, and if they are told they need residential treatment they must comply, or risk losing their licenses.

Doctors in the program routinely are monitored for five years after treatment. DuPont’s organization conducted the first national study of PHPs. In a follow up, they found that even five years after the required monitoring stopped, the large majority of physicians reported being completely abstinent from alcohol and other nonmedical drug use. “Most physicians after completing the PHP program are still abstinent and still going to 12-step meetings. The large majority report that the PHP program saved their lives and their careers,” says DuPont, who was also the second White House Drug Chief. “This study shows the way to make recovery, not relapse, the expected outcome of addiction treatment.”

New Paradigm programs treat addiction as a chronic illness. Just as blood sugar is monitored in a person with diabetes or blood pressure is measured for a person with hypertension, drug testing should be regularly conducted, eventually and ideally as part of routine medical care for patients in recovery from a drug or alcohol disorder, DuPont says. Two differences however, he notes, are the random nature of the drug testing, and the swift and certain consequences of a positive test result.

Some private addiction treatment programs, as well as independent monitoring services, use the New Paradigm. Several criminal justice system programs, including drug courts, also use the model. The New Paradigm can be especially useful in this setting, he observed. “In the criminal justice system today, a person on probation is tested on scheduled visits (not randomly) and they commonly have eight, 10 or even 15 substance abuse violations before being sent to prison often for long periods of time. That system of delayed, uncertain and draconian punishment does not work in anyone’s interests,” he says.

The New Paradigm begins with a signed mutual agreement between the person and the supervising entity (such as the family, an employer, or legal authority) to abstain from alcohol and drugs, and spells out the consequences of a failed drug or alcohol test. A successful program makes the consequence subject to the signed agreement, DuPont notes.  “For example, teens who fail drug tests could have their driving privileges revoked.” Employing such a system of a signed agreement enforced by frequent random testing makes it practical for families, employers, probation and others to support recovery far more effectively, he says.

The program strongly encourages, and usually requires, participants actively to engage in community-based support meetings, such as AA or NA.

The New Paradigm is not needed for everyone being treated for a substance use disorder, DuPont says. While it helps everyone, it is most needed for those who have had repeated relapses. “Even after a person has had terrible problems with substance use, the brain’s memory of the reward experience of using alcohol or drugs hijacks the person’s thinking. They believe they can go back and manage their alcohol and drug use this next time.” That is why DuPont is critical of treatment programs, including some medication-assisted treatment programs, which tolerate continued alcohol and other drug use while in treatment. “When a person comes into treatment, they seldom want to stop using alcohol and drugs —they want to cut down or to have a respite from the pain their use is causing them.”