Relapse: What Should We Do About It? Commentary on Flynn and Brown (2016)

Abstract

The thesis presented by Flynn and Brown (2015)makes two core assertions: first, the risk of relapse after treatment of substance abuse disorders is exceedingly high; second, most treatment programs and practitioners do not invest sufficient effort into preventing or dealing with relapse. They argue that these disorders should more properly be viewed as chronic relapsing disorders and that we need to restructure our health care system to deal with them as such, much in the way we deal with diabetes or hypertension. They are not alone in advancing this view. Given this perspective, current limits imposed by insurers or government agencies on how long or how frequently patients can be followed are seen as counterproductive. Flynn and Brown point to studies demonstrating that continuing caremodels (periodic follow-ups and communitymanagement check-ups) aimed at sustaining improvement and early re-engagement can be cost effective and, in some cases, show substantial benefit/cost ratios. They appear to believe that what is needed to make such periodic monitoring routine are appropriate economic incentives and revision of payment practices that limit reimbursement to active patients. They suggest that a good place to start would be with an Institute ofMedicine-like group of experts that couldmake recommendations for appropriate changes, and that the Affordable Care Act opens new possibilities for paying for more extended treatment. Some of these problems, such as the refusal of insurers and state governments to support demonstrably effective treatments as methadone maintenance, or irrationally limiting duration of coverage are more political than scientific and call for advocacy and litigation rather than scientific review. Continuing care (community management check-up) following a period of more intensive care is a different issue that will require persuading insurers and government agencies that expenditure on such activities is a better use of health care resources than expanding access to treatment. Could a group of experts help to accomplish this?What kinds of problemswould they confront when trying to recommend changes in the US health care system?What kinds of information will they be able to utilize? The number of random assignment controlled trials of posttreatment efforts aimed at sustaining improvement and intervening in relapses for any form of substance use disorder is relatively small. Most deal with patients that have either completed treatment or have participated in some significant amount of treatment. Very few deal with those who experienced only brief episodes. McKay (2009)