Managing Addiction as a Chronic Condition
TL;DR: Significant progress has been made in adapting addiction treatment to respond more fully to the chronic nature of most patients’ problems, and the importance of adjusting treatment funding and organizational structures to better meet the needs of individuals with a chronic disease is addressed.
Abstract: This article reviews progress in adapting addiction treatment to respond more fully to the chronic nature of most patients' problems. After reviewing evidence that the natural history of addiction involves recurrent cycles of relapse and recovery, we discuss emerging approaches to recovery management, including techniques for improving the continuity of care, monitoring during periods of abstinence, and early reintervention; recent developments in the field related to self-management, mutual aid, and other recovery supports; and system-level interventions. We also address the importance of adjusting treatment funding and organizational structures to better meet the needs of individuals with a chronic disease.
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TL;DR: This survey provides an extensive overview of RL applications in a variety of healthcare domains, ranging from dynamic treatment regimes in chronic diseases and critical care, automated medical diagnosis, and many other control or scheduling problems that have infiltrated every aspect of the healthcare system.
Abstract: As a subfield of machine learning, reinforcement learning (RL) aims at empowering one's capabilities in behavioural decision making by using interaction experience with the world and an evaluative feedback. Unlike traditional supervised learning methods that usually rely on one-shot, exhaustive and supervised reward signals, RL tackles with sequential decision making problems with sampled, evaluative and delayed feedback simultaneously. Such distinctive features make RL technique a suitable candidate for developing powerful solutions in a variety of healthcare domains, where diagnosing decisions or treatment regimes are usually characterized by a prolonged and sequential procedure. This survey discusses the broad applications of RL techniques in healthcare domains, in order to provide the research community with systematic understanding of theoretical foundations, enabling methods and techniques, existing challenges, and new insights of this emerging paradigm. By first briefly examining theoretical foundations and key techniques in RL research from efficient and representational directions, we then provide an overview of RL applications in healthcare domains ranging from dynamic treatment regimes in chronic diseases and critical care, automated medical diagnosis from both unstructured and structured clinical data, as well as many other control or scheduling domains that have infiltrated many aspects of a healthcare system. Finally, we summarize the challenges and open issues in current research, and point out some potential solutions and directions for future research.
245 citations
Cites background from "Managing Addiction as a Chronic Con..."
...iting patients’ preferences overtime. d) Substance Addiction: Substance addiction, or substance use disorder (SUD), often involves a chronic course of repeated cycles of cessation followed by relapse [183], [75]. There has been great interest in the development of DTRs by investigators to deliver in-time interventions or preventions to end-users using RL methods, guiding them to lead healthier lives. F...
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TL;DR: In the field of addiction treatment, the term "continuing care" has been used to indicate the stage of treatment that follows an initial episode of more intensive care as discussed by the authors, and it is possible that the effectiveness of continuing care interventions could be further improved by the use of adaptive algorithms, which adjust treatment over time based on changes in patients' symptoms and status.
238 citations
TL;DR: The overarching conclusion is that family-based models are not only a viable treatment alternative for the treatment of drug abuse, but are now consistently recognized among the most effective approaches for treating both adults and adolescents with drug problems.
Abstract: Just 15 years ago, Liddle and Dakof (Journal of Marital and Family Therapy, 1995; 21, 511) concluded, based on the available evidence, that family therapy represented a "promising, but not definitive" approach for the treatment of drug problems among adolescents and adults. Seven years later, Rowe and Liddle (2003) review described considerable progress in this specialty with encouraging findings on adolescent-focused models based on rigorous methodology, as well as advances with adult-focused family-based treatments. The current review brings the field up to date with highlights from research conducted in the intervening 7 years, cross-cutting issues, recommendations for new research, and practice implications of these findings. Adolescent-focused family-based models that attend to the ecology of the teen and family show the most consistent and strongest findings in recent studies. Adult-focused models based on behavioral and systems theories of change also show strong effects with drug abusers and their families. The overarching conclusion is that family-based models are not only a viable treatment alternative for the treatment of drug abuse, but are now consistently recognized among the most effective approaches for treating both adults and adolescents with drug problems.
225 citations
Cites background from "Managing Addiction as a Chronic Con..."
...Drug abuse tends to have its onset in adolescence, and new research suggests that longterm prognosis is better if drug treatment is received earlier in life and closer to the onset of the disorder (Dennis & Scott, 2007)....
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...Considering the cascading negative momentum created by deepening involvement with drugs, it may be naı̈ve to expect one treatment episode to produce and sustain radical life changes (Dennis & Scott, 2007; McLellan et al., 2000)....
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TL;DR: Qualitative data on current life priorities among a sample of individuals that collectively represent successive recovery stages suggest that many areas of functioning remain challenging long after abstinence is attained, most notably employment and education, family/social relations, and housing.
181 citations
Cites background from "Managing Addiction as a Chronic Con..."
...In fact, abstinence rarely brings instant relief (Vaillant, 1995); it is not atypical to see reductions in drug use without significant concurrent improvement in other life areas (Bacchus, Strang, & Watson, 2000; Dennis et al., 2007; McLellan et al., 1981)....
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TL;DR: Latent growth curve modeling analyses demonstrated the superior effectiveness of MDFT over the 12-month follow-up in reducing substance use and reducing risk in family, peer, and school domains among young adolescents.
Abstract: Research has established the dangers of early onset substance use for young adolescents and its links to a host of developmental problems. Because critical developmental detours can begin or be exacerbated during early adolescence, specialized interventions that target known risk and protective factors in this period are needed. This controlled trial (n 83) provided an experimental test comparing multidimensional family therapy (MDFT) and a peer group intervention with young teens. Participants were clinically referred, were of low income, and were mostly ethnic minority adolescents (average age 13.73 years). Treatments were manual guided, lasted 4 months, and were delivered by community agency therapists. Adolescents and parents were assessed at intake, at 6-weeks post-intake, at discharge, and at 6 and 12 months following treatment intake. Latent growth curve modeling analyses demonstrated the superior effectiveness of MDFT over the 12-month follow-up in reducing substance use (effect size: substance use frequency, d 0.77; substance use problems, d 0.74), delinquency (d 0.31), and internalized distress (d 0.54), and in reducing risk in family, peer, and school domains (d 0.27, 0.67, and 0.35, respectively) among young adolescents.
169 citations
Cites background from "Managing Addiction as a Chronic Con..."
...Examination of clinical samples reveals that the majority of individuals who go on to develop substance abuse problems initiated use in early adolescence (Dennis & Scott, 2007)....
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TL;DR: Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
Abstract: Crossing the Quality Chasm identifies and recommends improvements in six dimensions of health care in the U.S.: patient safety, care effectiveness, patient-centeredness, timeliness, care efficiency, and equity. Safety looks at reducing the likelihood that patients are harmed by medical errors. Effectiveness describes avoiding over and underuse of resources and services. Patient-centeredness relates both to customer service and to considering and accommodating individual patient needs when making care decisions. Timeliness emphasizes reducing wait times. Efficiency focuses on reducing waste and, as a result, total cost of care. Equity looks at closing racial and income gaps in health care.
15,046 citations
TL;DR: A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care.
Abstract: The dominant model of disease today is biomedical, and it leaves no room within tis framework for the social, psychological, and behavioral dimensions of illness. A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care.
8,359 citations
TL;DR: Comorbidity of addictive and severe mental disorders was highest in the prison population, most notably with antisocial personality, schizophrenia, and bipolar disorders.
Abstract: The prevalence of comorbid alcohol, other drug, and mental disorders in the US total community and institutional population was determined from 20 291 persons interviewed in the National Institute of Mental Health Epidemiologic Catchment Area Program. Estimated US population lifetime prevalence rates were 22.5% for any non—substance abuse mental disorder, 13.5% for alcohol dependence-abuse, and 6.1% for other drug dependence-abuse. Among those with a mental disorder, the odds ratio of having some addictive disorder was 2.7, with a lifetime prevalence of about 29% (including an overlapping 22% with an alcohol and 15% with another drug disorder). For those with either an alcohol or other drug disorder, the odds of having the other addictive disorder were seven times greater than in the rest of the population. Among those with an alcohol disorder, 37% had a comorbid mental disorder. The highest mental-addictive disorder comorbidity rate was found for those with drug (other than alcohol) disorders, among whom more than half (53%) were found to have a mental disorder with an odds ratio of 4.5. Individuals treated in specialty mental health and addictive disorder clinical settings have significantly higher odds of having comorbid disorders. Among the institutional settings, comorbidity of addictive and severe mental disorders was highest in the prison population, most notably with antisocial personality, schizophrenia, and bipolar disorders. (JAMA. 1990;264:2511-2518)
6,102 citations
01 Jan 2005
TL;DR: The authors call for applied research to better understand service delivery processes and contextual factors to improve the efficiency and effectiveness of program implementation at local state and national levels.
Abstract: In the past few years several major reports highlighted the gap between our knowledge of effective treatments and services currently being received by consumers. These reports agree that we know much about interventions that are effective but make little use of them to help achieve important behavioral health outcomes for children families and adults nationally. This theme is repeated in reports by the Surgeon General (United States Department of Health and Human Services 1999; 2001) the National Institute of Mental Health [NIMH] National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment (2001) Bernfeld Farrington & Leschied (2001) Institute of Medicine (2001) and the Presidents New Freedom Commission on Mental Health (2003). The authors call for applied research to better understand service delivery processes and contextual factors to improve the efficiency and effectiveness of program implementation at local state and national levels. Our understanding of how to develop and evaluate evidence-based intervention programs has been furthered by on-going efforts to research and refine programs and practices to define "evidence bases" and to designate and catalogue "evidence-based programs or practices". However the factors involved in successful implementation of these programs are not as well understood. Current views of implementation are based on the scholarly foundations prepared by Pressman & Wildavskys (1973) study of policy implementation Havelock & Havelocks (1973) classic curriculum for training change agents and Rogers (1983; 1995) series of analyses of factors influencing decisions to choose a given innovation. These foundations were tested and further informed by the experience base generated by pioneering attempts to implement Fairweather Lodges and National Follow-Through education models among others. Petersilia (1990) concluded that "The ideas embodied in innovative social programs are not self-executing." Instead what is needed is an "implementation perspective on innovation--an approach that views postadoption events as crucial and focuses on the actions of those who convert it into practice as the key to success or failure". (excerpt)
3,603 citations