This blog frequently discusses addiction as a chronic illness. The name of the game in treating chronic illnesses is to keep the patient in treatment and maintain high levels of compliance with the treatment plan. Addiction treatment providers are not alone in this struggle:
Doctors are very good at telling us what to do — but we are very poor at doing it. In fact, the health problems of millions of Americans are directly related to our failure to follow doctors’ orders.
Doctors tell us to take our pills, exercise, go get that C.T. scan, stop smoking, change our diets, cut out salt, quit drinking, monitor our blood sugar. We know we should do it, but we very often don’t. About three-quarters of patients do not keep appointments for follow-up care. In one study of diabetes patients, only 7 percent were compliant enough with their treatment plans to control the disease. Even people at grave and immediate risk do not always take their medicines: a quarter of kidney transplant patients in one studydid not take their medicines correctly, putting them at risk for organ rejection. Among elderly patients with congestive heart failure, 15 percent of repeat hospitalizations were linked to failure to take prescribed medicines. And compliance with exercise and diet programs is even worse. Poor compliance is a major reason that sick people don’t get better, and that our health care costs are so high. … Bad adherence doesn’t discriminate by social class. Tens of millions of Americans struggle with high cholesterol and blood pressure and yet can’t manage to stick to an exercise program.
On Tuesday, the NY Times describes a new approach to treating the most difficult patients:
Joe McManus is a 56-year-old former heroin and crack addict who lives in a single-resident-occupancy apartment in Manhattan. He spent 15 years as an addict, about 10 of them homeless. In some ways, he’s far from the typical homeless person. He used to work on Wall Street and still retains some of his Wall Street friends. … In other ways, he is absolutely typical of drug users who have hit bottom. McManus has AIDS, Hepatitis C and liver problems. … McManus was hospitalized four times in the year before November, 2009. Then he got a visit from Reynaldo Rodriguez.
When Rodriguez first visited McManus, he had already quit drugs, on his own. But he was still living as if he were homeless. His apartment was covered with soot and grime, the bed had cigarette burns and the refrigerator held moldy food. McManus was treating his apartment like it was the street. “How the hell are you living like this?” Rodriguez blurted out.
“I’m supposed to have a poker face, but I couldn’t keep it,” he said to me. “I couldn’t hold it in.”
On his second visit Rodriguez cleaned the room — something not in his job description . Rodriguez would pick up McManus before a doctor’s appointment, and they would get on the subway together and go. He made sure that McManus had the social work and housing help he needed. He made sure his prescriptions were filled. He’d work with McManus to organize his pills in his pillbox. But a lot of the time, the most useful thing Rodriguez did was just chat about the Yankees, or listen to McManus’ tales of his life. “It’s not just the educational piece and checking the pillbox,” he said. “It’s an opportunity to speak their stories. It’s showing that I’m going to be here regardless if you curse or slam the door.”
It made a difference. McManus started taking his medicines. The medicines brought down his viral load — he was getting better, and that motivated him to take care of himself. McManus is thin and twitchy, but when I saw him was dressed in jeans and a nice zippered sweater, and the apartment was in reasonable condition. McManus is now 100 percent adherent to his medicines, and his hospital stays amounted to only a single night in the last 16 months.
Today, the writer follows up with ideas for extending this concept to more patients in a sustainable, cost-effective manner:
Most of us don’t have the multiple serious illnesses and problems that McManus does, but a lot of us still share his basic challenge: how do we get ourselves to live more healthfully? We might need to eat better, quit smoking or drinking or exercise more. Instead of thinking of it as treatment adherence, we might call it keeping our New Year’s resolutions.
We don’t have a Rey Rodriguez to help us. But most of us have family, friends and neighbors, or other peers in our communities, who can help us stick to our health and medical regimens even if they have no medical training at all.
Joyce Strickland, for instance, volunteers for Rodriguez’s employer, the Center for Comprehensive Care (the program can only afford to pay her a small stipend), talking to people whose illness lands them in the hospital. She visits them in their rooms to urge them to begin coming to the clinic. She doesn’t have Rodriguez’s training in the curriculum of behavior change, but she does have something that can be equally valuable — a history of AIDS and drug abuse. She can talk to them about her own hesitation to disclose her disease to her family, her struggle to give up crack, her experience with the side effects of AIDS drugs. These are likely to be problems her patients share.
Some treatment providers (Dawn Farm, for one.) already do a good job helping clients build a small army of Rey Rodriguezes to coach them through early recovery and support their long term recovery. Then, like Joyce Strickland, the client becomes a coach for others.
However, this coaching relationship depends upon the addict exerting some effort. We’ve seen Project SAFE (More here and here) as well as the dissemination (and commercialization) of recovery coaching models that address this with assertive (rather than passive) recovery support approaches.
What we could do better with is turning the client’s existing support system into coaches—these relationships would be more likely to persist regardless of client effort.