Review Article, J Addict Behav Ther Rehabil Vol: 8 Issue: 2
Community as Treatment: The Therapeutic Community Model in The Era of The Opioid Crisis
Received: June 06, 2019 Accepted: June 20, 2019 Published: June 30, 2019
Citation: Kast KA, Manella G, Avery J (2019) Community as Treatment: The Therapeutic Community Model in The Era of The Opioid Crisis. J Addict Behav Ther Rehabil 8:2.
Increased attention to additional treatment approaches for Opioid Use Disorder (OUD) is needed amidst the current opioid crisis. The Therapeutic Community (TC) is an effective model that offers a unique treatment frame for patients considered “treatment-resistant”, yet it is rarely considered an option in the United States and has not been included in the federal response to the opioid crisis. We explore the evidence supporting the TC modality as uniquely effective and use a current Italian model-San Patrignano, the largest TC in the world-to identify salient mediators of the outcome, including long-term treatment and removal from the opioid-associated environment. The potential role of the TC in responding to the opioid crisis in the United States and its compatibility with other standard-of-care treatments are reviewed
Keywords: Medication-assisted treatment; The opioid epidemic; San Patrignano; Substance use disorders; Therapeutic
The Therapeutic Community (TC) model for Opioid Use Disorder (OUD) should be placed within the larger system of care for individuals living with addiction in the United States.
Currently, only a minority of patients receive appropriate first-line Medication-Assisted Treatment (MAT) for OUD [1,2]. Efforts to increase access to these interventions are appropriate and much-needed. Yet MAT and harm-reduction interventions do not lead to remission or risk-reduction for all OUD patients; 6-month retention rates in our best clinical studies of MAT are 30%-50% . A significant group continues opioid use with its grave risks despite our first-line treatments.
Increased attention to additional treatment approaches for Opioid Use Disorder (OUD) is especially needed amidst the current opioid crisis. The Therapeutic Community (TC) is an effective model that offers a unique treatment frame for patients considered “treatment-resistant”, yet it is rarely considered an option in the United States and has not been included in the federal response to the opioid crisis.
Yes, we need to expand access to MAT; and we need to diversify the available treatment modalities. Further, MAT and TCs are not exclusive of each other-though there are historical roots to their apparent segregation .
We explore the evidence supporting the TC modality as uniquely effective and use a current Italian model-San Patrignano, the largest TC in the world-to identify salient mediators of the outcome, including long-term treatment and removal from the opioidassociated environment. The potential role of the TC in responding to the opioid crisis in the United States and its compatibility with other standard-of-care treatments are reviewed.
The Opioid Epidemic and Medication-Assisted Treatment
Opioid Use Disorder (OUD) affects 2.5 million people in the United States and is associated with increased rates of emergency medical service utilization, infectious disease transmission (including human immunodeficiency virus and viral hepatitis), obstetrics and neonatal complications, impaired social and occupational functioning, legal system involvement, homelessness, and death . Over the past decade, OUD and its associated morbidity and mortality have received increasing attention from national public health authorities, medical professional organizations, federal and local government, and the lay press in the United States. The epidemic of prescription opioid overdose deaths, which quadrupled between 1999 and 2011 and reached a peak of 72,000 total drug overdose deaths per year in 2017, has motivated a series of federal responses, including the Comprehensive Addiction and Recovery Act (CARA) of 2016 [2,6-8].
CARA’s implementation has emphasized increasing access to currently-underutilized medication-assisted treatment (MAT; methadone, buprenorphine, or naltrexone formulations) and naloxone-based and other harm-reduction measures against overdose deaths. These are evidence-based interventions with proven efficacy in reducing relapse and OUD-related death, OUD-related infectious disease transmission, criminal recidivism, as well as increasing treatment retention [2,9-11]. Despite this evidence base, only a minority of patients receive appropriate MAT, and efforts to increase access to these interventions are much-needed [1,2].
However, a significant group continues opioid use with its grave risks despite our first-line treatments. Further, some patients have relative medical contraindications or aversions to one or all of the hree medications, limiting their ability to benefit from this approach.
Additionally, the current system of care wherein MAT is delivered emphasizes short-term rehabilitation, with 15, 30, or 60-day Lengthsof- Stay (LOS) being most common. This is problematic in light of the multiply-replicated finding that greater LOS improves outcomeswith a clear inflection point at 90 days and continued benefit with even longer treatment for more severely-impaired individuals [12-15]. Short-term rehabilitation is also often not covered by insurance can require patients and families to pay large sums of money to attend the short-term rehabilitation center with the best care.
Box 1-idealized case vignette
James is a 23-year-old man with a history of congenital Long QT Syndrome (LQTS), Obsessive-Compulsive Disorder (OCD), and opioid use disorder. He started using prescription opioids at age 16, and by the time he was 18, he was homeless and using opioids daily. He presented in crisis to multiple emergency rooms, brief medicallysupervised withdrawal programs (detoxification, or “detoxes”), and 30- or 60-day short-term rehabilitation programs, but would quickly relapse when discharged from these brief settings. Due to his LQTS, clinicians were reluctant to prescribe methadone or buprenorphine, and his fear of needles prevented him from receiving long-acting injectable naltrexone. His intermittent adherence to oral naltrexone was predictably ineffective in sustaining recovery. His parents estimated that they spent $300,000 on his care during those 2 years. At age 18, when faced with the possibility of going to jail, he elected to join the San Patrignano Community in Italy. James attended this free therapeutic community for three years, and returned to the United States “a different person”. He has since started college and remains abstinent from substances.
Therapeutic Communities: A Re-introduction
The Therapeutic Community (TC) modality offers an additional approach to the treatment of OUD, with unique mechanisms of action-including longer LOS, cognitive schema change, increased mentalization capacity, social learning, and educational/occupational habilitation-that may either complement current standards-of-care or serve as monotherapy for patients with severe, treatment-refractory OUD [16-21]. TCs have been effective in leading to sustainedremission for OUD patients with significant markers of poor prognosis, including multiple substance use disorders, psychiatric comorbidity, personality disorder, poor work history, and criminality .
Brief historical note
Therapeutic communities for addiction arose in the United States in the late 1950s and early 1960s out of the peer-led 12-step tradition of Alcoholics Anonymous . The first communities, Synanon (founded 1958) and Daytop Village (founded 1963), emerged outside traditional healthcare systems; in fact, these early TCs have been identified both as an “alternative” to medical models of addiction treatment and as a part of the larger “anti-psychiatry” movement in the United States . This in part explains the historical strict avoidance of psychotropic medications in TCs; the early abstinencebased model extended beyond alcohol and illicit drugs-it included mind-altering medications for psychiatric disorders, which were only beginning to be developed in the 1950s-1960s, with the first antidepressants and antipsychotics.
Methadone maintenance therapy, which was being studied for the treatment of OUD at the Rockefeller Institute in 1964, was initially viewed as a threat to sobriety and recovery by those in the early TC model. This historical perspective has been challenged with some difficulty, as the first study to ask if patients taking methadone can be successfully treated within a therapeutic community model was published relatively recently in 2009 .
Although traditionally espousing abstinence-based recovery, increasingly TCs incorporate MAT and other evidence-based treatments-including cognitive-behavioral, motivational interviewing, and relapse-prevention approaches-into treatment plans for patients [17,19]. Modern TCs are integrating into the overall system-of-care for addicted patients, with many now offering expanded services in primary medical care, mental health care, relapse-prevention training, and aftercare case-management [12,23].
Core components of the model
The core therapeutic approach is simply “community as method”, meaning the purposeful use of a social structure to teach patients to use the community to change themselves . The structure of the TC has evolved over the decades, with many modifications in response to different patient populations (including pregnant women, adolescents, and prisoners) and increasing fiscal pressure to shorten Length-of-Stay (LOS) from the original 12-24 month’s duration.
TCs uniformly provide a stable residence in shared communal spaces that are sequestered from the prior drug-associated environment. They require urine toxicological screening and surveillance for all members. LOS is purposefully long-term, ranging from 3-36 months, and is individualized to each community member. The community has a clear social structure, including peer and professional staff (typically, ~50% peer-based) who serve to facilitate the planned community organization. Participation in structured community-enhancing activities for meals, work, groups, celebration, and leisure is asked of each individual.
The model intensifies social learning, using participation in regular peer encounter groups with corrective “pull-ups” and affirming “push-ups” from peers to shape behavior toward shared community values and right-living. Additional behavioral feedback occurs via privileges earned to reward progression in the program and disciplinary sanctions for violations of rules protecting patient and staff safety and program culture. There are also straightforward educational seminars around the fundamental philosophy and concepts of peer-led 12-step programs.
While living in the TC, every individual participates in communal work managing the facilities and commercial enterprises of the community, providing a matrix of upward mobility and mastery. In some TCs, continuing education and vocational training is highly developed, with members earning college degrees or certified trade expertise.
Progression in the community occurs along with three phases of recovery, moving from initial induction to primary treatment to reintegration and planning to leave the community. As re-entry into society nears, issues around post-discharge housing, employment, venues for continued contact with peer-led support groups, and medical and psychiatric follow-up care are addressed to solidify gains made in the community [17,22].
Target patient population
Appropriate matching of patient characteristics with recommended level-of-care is important in determining suitability for TC-based treatment [24-27]. Individuals with more impairment in interpersonal, occupational, and ethical/legal functioning benefit from inpatient or residential treatment settings and longer LOS . Housing status may also be important to consider . The population served by modern TCs typically presents with significant poor prognostic indicators, including multiple substance use disorders (most commonly cocaine, cannabis, alcohol, and tobacco), psychiatric comorbidity (usually anxiety-spectrum disorders, but also affective and psychotic disorders), personality disorder (including antisocial, borderline, hysteric, schizotypal, and avoidant traits), poor work history (two-thirds not employed full-time over the year preceding treatment), and criminality (with a majority having prior arrests and legal action) . Patients thought to be particularly wellsuited for referral to TCs have evidence of a life in crisis (including felt anxiety around the risk of serious harm or death due to continued OUD and/or identified losses due to substance use), inability to maintain abstinence despite prior treatment episodes, grave social or interpersonal dysfunction (with few relationships and little-to-no employment), and/or an antisocial lifestyle .
Efficacy and effectiveness
Significant evidence from large-scale naturalistic field effectiveness studies, single-program controlled studies, randomizedcontrolled trials, meta-analyses, and cost-benefit analyses support TCs as effective, cost-saving interventions for more-impaired patients [13,14,30]. Patient outcomes measured include sustained abstinence, reduced drug use, criminal behavior, and employment; cost-benefit analyses show reduced healthcare-related costs and carbon-footprint of treatment .
Notably, some authors have called into question the quality of evidence supporting TCs’ efficacy, often excluding significant field effectiveness studies in exclusive favor of randomized-controlled trials; [32-34] this restricted view of the available literature has itself been called into question, emphasizing the utility of effectiveness (as opposed to efficacy) studies in clinical populations and treatments whose complexity rivals that of a university education .
Moderators of Response and Mechanism of Action
The major moderator of response to TC-based intervention is retention in treatment and longer LOS [12-15] The active therapeutic components of the “community as method” model is an empirical question under investigation. There is evidence for the following mediators: increased capacity for responsible agency, development of a sense of social belongingness, engagement in a productive pattern of corrective feedback (“pull-ups” and “push-ups”) given and received in social learning, increased internal self-identification with recovery over substance use, cognitive schema change toward TC-based “right-living”, increased mentalization capacity, and educational/ occupational habilitation [16,18,21,35-37].
Notably, the TC model shares characteristics of Winnicott’s theory of a psychodynamic holding environment (and Bion’s theory of containment), fostering a sense of safety and trust necessary for self-exploration and providing optimal frustration of patients’ habitual methods of obtaining satisfaction and relieving internal tension [18,38]. This is thought to allow for a growing capacity to mentalize one’s own and others’ cognitive-emotional states (moving away from relative alexithymia) and develop reflective functioning necessary for behavior change-an important mechanism known to be active in psychotherapies targeting severe personality disorders .
These hypothesized therapeutic mediators of “community as method” may work on different neurobiological substrates than MAT and other evidence-based interventions. Analogous synergistic effects of psychotropic medication and psychosocial interventions via divergent underlying neural substrates in the treatment of major depressive disorder suggest the possibility of enhanced efficacy for OUD when combining MAT and TCs-though this remains an empirical question to be demonstrated and may vary by individual patient characteristics .
An additional area of further study is the use of neuroimaging modalities in TC populations, interrogating underlying changes or neuroadaptations involved in long-term (as compared with shortterm) recovery. There is data suggesting progressive recovery of some neuroimaging findings thought to be associated with active addiction, though some changes do not appear to recover despite long-term abstinence [41-47]. The TC population offers a unique opportunity to study the neurocircuitry underlying improved outcomes with LOS >90 days.
San Patrignano: An Example Of The TC Italian Model
San Patrignano (SanPa), the world’s largest TC with a current census of 1,300, was founded in Coriano, Italy in 1978 by Vincenzo Muccioli and has welcomed over 30,000 patients throughout its history. SanPa’s LOS is 36 months, with concurrent occupational training at one of 50 work sites . SanPa has a long history of effectively treating individuals with OUD with retrospective data demonstrating high retention in treatment and durable remission at up to four-years follow-up . Further, treatment at SanPa is provided free of charge, financially sustaining its services via the community’s significant and patient-led commercial enterprises and private donation . Examining the Italian TC model suggests a role for this modality in responding to the current opioid crisis in the United States, especially for the patients not sufficiently helped by current standards-of-care.
“The Italian Model” of TCs
Pieretti has suggested that the Italian model for therapeutic communities is unique . A defining feature is the therapeutic stance of social accompaniment (accompagnamento sociale where TC staff is not “superior” in the implementation of the helping process-they do not act as “mothers” or “fathers” but rather as “brothers” or “sisters” alongside the individuals seek help) [52,53]. Universal acceptance is also a common rule: accepting people into the community in any state or condition, and regardless of any prior treatment experiences or failures. There is no “standard” patient, and so Italian TCs report no “standard” therapy or methodologyflexibility in meeting the patient “where they are” is crucial.
Informed by this accepting and accompanying stance, the Italian model is expressed as a “collective management of the crisis of presence” (gestione collettiva della crisi della presenza), where the close proximity, or “presence”, of a community of others is the central dynamic confronting the individual. Patients face an intensive experience of self-examination and accountability to the community, with the motivation for social acceptance and belonging driving cohesion and behavior change in alignment with community values.
In Italy, “community as method” means to recursively use the community to help the individual address the critical challenge of living within the community.
San Patrignano’s outcomes
Multiple studies of SanPa’s therapeutic method, organization, and outcomes have been completed [49,54-56]. In the 2005 follow-up, retention in treatment was 66% after 12 months, 53% at 24 months, and 45% at 36 months. 287 former patients (56.2% of 511 contacted) with at least 36-month’s LOS completed rigorous toxicological testing (assessing for prior 90-day use via hair-sampling). At 2-4 years’ postdischarge, 72-78% of these individuals sustained abstinent recovery. This outcome was achieved despite 38% of these patients having >11-years’ duration of SUD; within this more treatment-refractory sub-group, 60% remained alive and in sustained abstinent recovery. Most were employed and living independently from family, with 40% having partnered. Of those who experienced relapse, risk was greater for men (22% relapse vs. 11.5% for women), for those who left SanPa without community consent (37% relapse vs 17.6% among those leaving with consent), and for shorter LOS (28% for 3-4 years vs. 11% for 5+ years) .
The earliest study also included qualitative feedback elicited from patients who had completed at least 14 months at SanPa (limited by a 30.9% response rate; 711 of the 2,300 individuals who met inclusion criteria) . A “city effect”, or the experience of the community as a large complex social system with unique culture (like that of a city), was found to positively affect engagement for these patients. Work at occupational sites also had a dual effect of promoting group cohesion and recovery of personal dignity .
James’ case, described in box 1, illustrates an important population of patients with OUD who are unable to benefit from current first-line treatments, whether due to intolerance and dropout, relative contraindications, or patient preference. His family’s burdensome debt also highlights an important fiscal reality: shortterm rehabilitation is too expensive for most patients and their families-and the cost-barrier has even led to bizarre, desperate, and risky behaviors to qualify for needed insurance coverage. Patients like James, for whom short-term residential treatment in combination with MAT fails to lead to stable recovery-or for whom evidence-based medications for opioid use disorder are intolerable-likely require >90 days LOS (and perhaps longer) to achieve sustained remission. In the United States, too often long-term rehabilitation takes the form of a prison sentence for non-violent drug-related crimes.
Despite the evidence for effective treatment of a marginalized and treatment-resistant population and the potential for synergistic effects with other evidence-based treatments, TCs have not yet been included in the federal response to the opioid crisis . In contrast, American prisons and correctional settings have shown increasing interest in TC models, with programs in New York, California, Texas, Virginia, Colorado, and Delaware demonstrating less recidivism, increased employment, and better SUD-related outcomes . Although encouraging, this highlights a problematic historical trend in the United States: an over-reliance on an under-equipped legal and correctional system to manage mental illness and substance use disorders . Further, these prison-based TCs highlight the importance of ongoing treatment after release, with marked effects on relevant outcomes. Thus, the availability of non-corrections-based programs is important for these individuals, as well as those not (yet) with legal repercussions to their substance use.
Access to multiple effective treatment modalities with flexible levels-of-care would seem to increase the likelihood of engaging a diverse population of individuals with opioid and other substance use disorders. This is an important hypothesis since only 19.3% of individuals with SUD in the United States received any treatment in 2017 (and only 12.2% received treatment in a specialty facility); a significant treatment gap. Yes, expand access to MAT; and increase access to other effective treatments, like therapeutic communities, that may complement MAT and diversify available modalities for a largely unengaged population. Future work here in the United States might focus on dedicating existing resources for building or sustaining TCs. This may especially valuable for individuals like James, who couldn’t safely live in the community with existing treatment options here in the United States.
We identify a need for increased attention to additional treatment approaches to OUD amidst the current opioid crisis. MAT, shortterm rehabilitation, and harm-reduction strategies are evidence-based and effective but do not lead to remission for all OUD patients. The TC model offers a unique treatment frame to address this treatmentresistant population and may at times be preferred by patients over our current first-line interventions. Unique mechanisms of actionincluding social learning, cognitive schema change, increased mentalization capacity, and vocational habilitation-may complement MAT or serve as monotherapy for patients with severe, treatmentrefractory OUD. Significant evidence from large-scale naturalistic field effectiveness studies, single-program controlled studies, randomized-controlled trials, meta-analyses, and cost-benefit analyses support TCs as effective, cost-saving interventions for moreimpaired patients. TCs should be considered an important modality in addressing the opioid crisis, and patients should be offered TCbased treatment as an evidence-based, effective alternative.
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