Why won’t the acute care paradigm die?

Recently, I posted about a study finding significant declines in the duration of treatment for MOUD patients in Ontario, Canada. The post focused on the persistence of the acute care paradigm, now appearing in MOUD.

The post prompted some discussion on LinkedIn, during which I was struck by how this is really just a cycle repeating. Over-promising what a treatment can deliver, failing to adopt recovery management, and the acute care model takes another victim.

25 years ago, when Bill White started challenging the field to abandon the acute care paradigm, it was psychosocial treatments like residential and IOP that were the guilty parties.

At that time, the field was consumed with competition between 12-Step Facilitation, CBT, and Motivational Enhancement Therapy for recognition as the most effective treatment model.

Bill would admonish the audience that these arguments were taking place within the acute care paradigm, and that the acute care paradigm needed to be abandoned for the treatment of the chronic illness of addiction. All therapeutic models delivered within the acute care paradigm will fail when applied to addiction.

Why won’t the acute care paradigm die?

It’s not as though there’s an explicit acute care lobby to protect and advance it; yet it persists. Why?

Off the top of my head, here are some of the potential contributors I came up with.

Research

Favors what is easily measurable.
Favors what can produce published articles in the near term.
The emphasis on empirical knowledge can lead to the neglect of experiential and real-world knowledge. In some cases, it can contribute to scientism.

Professional interests

The APA produces the DSM-5, which puts all substance use problems into a single category (SUD), many of which may only require brief interventions, while others will require long-term disease/recovery management.
The history of public responses to alcohol and other drug (AOD) problems is one of various systems and professional interests competing for cultural ownership of the problem. Social marketing of these professional groups often involves silver bullets and simple narratives that align with the acute care paradigm.

Medicine

Remission (symptom reduction) is generally the focus in medicine.
Social Determinants of Health are out of scope. May be identified, but referred out.
- SDOH represent a lot of recovery capital work in Recovery Management and Recovery-Oriented Systems of Care.
Passive engagement is the norm.
Still not great at long-term behavioral chronic disease management strategies.
Favors pills and procedures over behavioral management.

Payers

Reimbursement doesn’t promote long-term recovery management.
Favors disease management incentives with simple practices, like screening or prescribing (eg blood pressure meds or statins).
Emphasis on evidence-based practices focuses on effect, effect size, and measurability. Favors short-term interventions and outcomes.¹

Public health

Focused on portions of population bell curves with the largest number of people, but addiction exists in the tail.
Public health interventions focus on changing social norms and target populations for intervention rather than individuals.
Individual experiences of public health interventions are typically brief.

Advocacy

The push to establish large numbers has led to the conflation of low severity and acute problems with addiction.
Recovery prevalence data extended recovery to people who had ever had a problem with alcohol and other drugs (AOD) and consider that problem resolved.
Previous public education and advocacy tried to distinguish addiction (chronic, severe, progressive, and characterized by impaired control) from other AOD problems.
Advocacy movements rejected historical exclusionary boundaries for recovery that confined the concept to people with addiction (not just SUD, which includes much lower severity problems) and pursued stable recovery through abstinence plus psycho-social-spiritual changes.
This advocacy emphasizes that many people resolve their problems without treatment or mutual aid.
An acute care model may be appropriate for people with lower severity and acute problems.
The difference between recovery and remission is less clear, as the boundaries of recovery and the prerequisite condition expand. Remission is easier to observe and measure in the short term.

Treatment

Treatment-oriented and short-term measures are super seductive because they are easier to measure and market.
Recovery is something that happens outside of treatment, in family, community, and occupational life. Difficult for them to capture, especially when there’s little agreement on the boundaries of recovery and you are underfunded.
Other kinds of care aren’t expected to do long-term monitoring and outcome reporting. Use of an evidence-based practice is sufficient.

People with addiction and their loved ones

The idea that a time-limited episode of care will result in stable recovery. Many of us are probably too willing to embrace that notion and share it with others.

These are the thoughts that came to mind as I considered the persistence of the acute care paradigm. This isn’t to lay blame, but rather to understand the forces that contribute to its survival.

What have I missed or misunderstood?