health settings who smoke may be even less
likely to receive the smoking cessation services
they need.^123 Psychiatrists may eschew smoking
cessation interventions because they believe
“patients have more immediate problems to
address;” some medical and other health
professionals also may be reluctant to encourage
smoking cessation because they feel it “gives
patients with psychiatric illnesses comfort while
dealing with their mental illness symptoms.”^124
Contrary to these beliefs, research shows that
smokers with mental health conditions are as
motivated as those in the general population to
quit smoking^125 and one study showed that the
majority (79 percent) of mentally ill smokers
want to quit.^126
Interventions Rarely are Tailored to Patient
Characteristics that Might Affect Treatment
Outcomes. Not taking into account a patient’s
age, gender, race/ethnicity, socioeconomic status
or system of personal supports in designing a
treatment intervention can compromise
otherwise effective treatment plans.
Chapter VI of this report outlines specific
treatment needs of special populations and
Chapter VII shows the gaps in needed treatment
for some of these groups. While the baseline
level of addiction-related services offered to the
general population is inadequate, the deficiency
in tailored services offered to populations with
special treatment needs is even more glaring.^127
Chronic Disease Management ...................................................................................
For many individuals, addiction manifests as a
chronic disease, requiring disease and symptom
management over the long term.^128 In recent
years, there has been growing recognition of the
importance of comprehensive disease
management in the treatment of chronic health
conditions for which there is no known cure,
where relapse episodes are considered an
expected part of the disease course and where
long-term symptom management is considered
routine care. While this approach increasingly
has been adopted for diseases such as
diabetes,^129 hypertension^130 and asthma,^131
addiction treatment largely remains stuck in the
acute-care model.^132
Patients with addiction, regardless of the stage
and severity of their disease, typically receive a
diagnosis followed by a swift course of
treatment administered by individuals without
any medical training and then minimal to no
follow-up care.^133 In contrast to other chronic
diseases, positive results from a short-term
intervention or treatment for addiction are
expected to endure indefinitely and relapse
commonly is viewed as a sign of treatment
failure, at best, and as evidence of a deficit in
patients’ willpower or dedication to managing
their condition, at worst, rather than as a result
of inadequate treatment or follow-up care.^134Evidence of the acute care approach to addiction
treatment is that current Medicare and Medicaid
regulations indicate that hospital readmissions
for patients with addiction involving alcohol are
not to be treated as extensions of the original
treatment but rather as a new admission to treat
the same condition. Readmissions can be seen
as evidence that treatment is not working and
typically are not covered unless a physician can
document a change in the patient’s physical,
emotional or social condition that makes it
reasonable to expect that additional treatment
would improve the patient’s condition, or
documents why the initial treatment was
insufficient.^135 Given that addiction often is a
chronic disease and that relapse is possible,
limitations on hospital readmissions may reduce
access to needed care and reflect a fundamental
mischaracterization of the disease and its
expected course of treatment.