Integrating primary medical care with addiction treatment: a randomized controlled trial.
TL;DR: Individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective.
Abstract: ContextThe prevalence of medical disorders is high among substance abuse patients,
yet medical services are seldom provided in coordination with substance abuse
treatmentObjectiveTo examine differences in treatment outcomes and costs between integrated
and independent models of medical and substance abuse care as well as the
effect of integrated care in a subgroup of patients with substance abuse–related
medical conditions (SAMCs)DesignRandomized controlled trial conducted between April 1997 and December
1998Setting and PatientsAdult men and women (n = 592) who were admitted to a large health maintenance
organization chemical dependency program in Sacramento, CalifInterventionsPatients were randomly assigned to receive treatment through an integrated
model, in which primary health care was included within the addiction treatment
program (n = 285), or an independent treatment-as-usual model, in which primary
care and substance abuse treatment were provided separately (n = 307) Both
programs were group based and lasted 8 weeks, with 10 months of aftercare
availableMain Outcome MeasuresAbstinence outcomes, treatment utilization, and costs 6 months after
randomizationResultsBoth groups showed improvement on all drug and alcohol measures Overall,
there were no differences in total abstinence rates between the integrated
care and independent care groups (68% vs 63%, P =
18) For patients without SAMCs, there were also no differences in abstinence
rates (integrated care, 66% vs independent care, 73%; P = 23) and there was a slight but nonsignificant trend of higher costs
for the integrated care group ($36796 vs $32409, P
= 19) However, patients with SAMCs (n = 341) were more likely to be abstinent
in the integrated care group than the independent care group (69% vs 55%, P = 006; odds ratio [OR], 190; 95% confidence interval
[CI], 122-297) This was true for both those with medical (OR, 338; 95%
CI, 168-680) and psychiatric (OR, 210; 95% CI, 104-425) SAMCs Patients
with SAMCs had a slight but nonsignificant trend of higher costs in the integrated
care group ($47081 vs $42795, P = 14) The incremental
cost-effectiveness ratio per additional abstinent patient with an SAMC in
the integrated care group was $1581ConclusionsIndividuals with SAMCs benefit from integrated medical and substance
abuse treatment, and such an approach can be cost-effective These findings
are relevant given the high prevalence and cost of medical conditions among
substance abuse patients, new developments in medications for addiction, and
recent legislation on parity of substance abuse with other medical benefits
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TL;DR: Receipt of primary medical care is associated with improved addiction severity, and these results support efforts to link patients with addictions toPrimary medical care services.
Abstract: AIMS To assess whether receipt of primary medical care can lead to improved outcomes for adults with addictions. DESIGN We studied a prospective cohort of adults enrolled in a randomized trial to improve linkage with primary medical care. METHODS Subjects at a residential detoxification unit with alcohol, heroin or cocaine as a substance of choice, and no primary medical care were enrolled. Receipt of primary medical care was assessed over 2 years. Outcomes included (1) alcohol severity, (2) drug severity and (3) any substance use. FINDINGS For the 391 subjects, receipt of primary care (> or = 2 visits) was associated with a lower odds of drug use or alcohol intoxication (adjusted odds ratio (AOR) 0.45, 95% confidence interval (CI) 0.29-0.69, 2 d.f. chi(2)P = 0.002). For 248 subjects with alcohol as a substance of choice, alcohol severity was lower in those who received primary care [predicted mean Addiction Severity Index (ASI) alcohol scores for those reporting > or = 2, 1 and 0 visits, respectively, 0.30, 0.26 and 0.34, P = 0.04]. For 300 subjects with heroin or cocaine as a substance of choice, drug severity was lower in those who received primary care (predicted mean ASI drug scores for those reporting > or = 2, 1 and 0 visits, respectively, 0.13, 0.15 and 0.16, P = 0.01). CONCLUSIONS Receipt of primary medical care is associated with improved addiction severity. These results support efforts to link patients with addictions to primary medical care services.
95 citations
TL;DR: Common SUDs, particularly opioid use disorders, are associated with substantial disease burden for privately insured individuals without significant impediments to care, and signals the need to explore the full impact Suds have on the course and outcome of prevalent conditions and initiate enhanced service engagement strategies to improve disease burden.
Abstract: Author(s): Bahorik, Amber L; Satre, Derek D; Kline-Simon, Andrea H; Weisner, Constance M; Campbell, Cynthia I | Abstract: ObjectivesWe examined prevalence of major medical conditions and extent of disease burden among patients with and without substance use disorders (SUDs) in an integrated health care system serving 3.8 million members.MethodsMedical conditions and SUDs were extracted from electronic health records in 2010. Patients with SUDs (n = 45,461; alcohol, amphetamine, barbiturate, cocaine, hallucinogen, and opioid) and demographically matched patients without SUDs (n = 45,461) were compared on the prevalence of 19 major medical conditions. Disease burden was measured as a function of 10-year mortality risk using the Charlson Comorbidity Index. P-values were adjusted using Hochberg's correction for multiple-inference testing within each medical condition category.ResultsThe most frequently diagnosed SUDs in 2010 were alcohol (57.6%), cannabis (14.9%), and opioid (12.9%). Patients with these SUDs had higher prevalence of major medical conditions than non-SUD patients (alcohol use disorders, 85.3% vs 55.3%; cannabis use disorders, 41.9% vs 23.0%; and opioid use disorders, 44.9% vs 26.1%; all P l 0.001). Patients with these SUDs also had higher disease burden than non-SUD patients; patients with opioid use disorders (M = 0.48; SE = 1.46) had particularly high disease burden (M = 0.23; SE = 0.09; P l 0.001).ConclusionsCommon SUDs, particularly opioid use disorders, are associated with substantial disease burden for privately insured individuals without significant impediments to care. This signals the need to explore the full impact SUDs have on the course and outcome of prevalent conditions and initiate enhanced service engagement strategies to improve disease burden.
95 citations
Cites background from "Integrating primary medical care wi..."
...Prior studies have also found that patients with SUDs and comorbid medical conditions have better alcohol and drug use outcomes when SUD treatment is integrated with primary care (Weisner et al., 2001; Friedmann et al., 2003)....
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...Research has previously shown that patients with SUDs suffer disproportionately from medical conditions associated with or exacerbated by substance use (Ray et al., 2000; Weisner et al., 2001; Mertens et al., 2003)....
[...]
...Polysubstance use disorders are associated with a number of major medical conditions (Weisner et al., 2001; Mertens et al., 2003), and they place individuals with alcohol, cannabis, and opioid use disorders who have these conditions at an elevated risk for poor health outcomes, including high morbidity and early mortality (Schuckit, 2009; Hall and Degenhardt, 2009; Volkow et al....
[...]
..., 2016), and patients with alcohol, cannabis, and opioid use disorders were significantly more likely to have 1 or more medical conditions than their non-SUD counterparts (Weisner et al., 2001; Mertens et al., 2003)....
[...]
...…SUDs (Edlund et al., 2007; Hall and Degenhardt, 2009; Schuckit, 2009; Brady et al., 2016), and patients with alcohol, cannabis, and opioid use disorders were significantly more likely to have 1 or more medical conditions than their non-SUD counterparts (Weisner et al., 2001; Mertens et al., 2003)....
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TL;DR: Self-initiated smoking cessation does not appear to be detrimental to SA treatment outcomes, and may be beneficial, and starting/resuming smoking after entering SA treatment may be a clinical marker for individuals at greater risk of relapse.
93 citations
TL;DR: The PRISM-E study indicates the need for screening in primary care and for engaging older adults in treatment and shows a higher preponderance of younger ages, women, and ethnic minorities among patients with mental health problems and at-risk alcohol use.
Abstract: Objective: To describe the design of the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study and baseline characteristics of the randomized primary care patients with mental health problems and at-risk alcohol use. Method: Adults aged 65 and older were screened at primary care clinics from 10 study sites throughout the United States. Those diagnosed for depression, anxiety, and/or at-risk alcohol consumption were randomized to either integrated or enhanced referral care. Results: Of the 23,828 participants, 14% had a positive assessment for depressive and/or anxiety disorders, and 6% had at-risk alcohol consumption diagnoses. Among patients with mental health diagnoses, there was a higher preponderance of younger ages, women, and ethnic minorities. Among patients with at-risk drinking, there was a higher preponderance of younger ages, Whites, and men. Discussion: These findings indicate the need for screening in primary care and for engaging older adults in treatment.
91 citations
Cites result from "Integrating primary medical care wi..."
...Unlike previous studies that have examined either major or minor depression (e.g., Katon et al, 1995; Weisner et al., 2001), the PRISM-E study includes the spectrum of depression, anxiety, at-risk drinking, and comorbid MH/SA disorders that present among the elderly in primary care settings....
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TL;DR: The findings for the full sample suggest that integrating substance abuse treatment with primary care, may not be necessary or appropriate for all patients, but it may be beneficial to refer patients with substance abuse related medical conditions to a provider also trained in addiction medicine.
Abstract: Objective. To examine the impact of integrating medical and substance abuse treatment on health care utilization and cost.Research Design. Randomized clinical trial assigning patients to one of two treatment modalities: an Integrated Care model where primary health care is provided along with substa
89 citations
References
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01 Jan 1993TL;DR: This article presents bootstrap methods for estimation, using simple arguments, with Minitab macros for implementing these methods, as well as some examples of how these methods could be used for estimation purposes.
Abstract: This article presents bootstrap methods for estimation, using simple arguments. Minitab macros for implementing these methods are given.
37,183 citations
TL;DR: The clinical and research uses of the ASI over the past 12 years are discussed, emphasizing some special circumstances that affect its administration.
4,045 citations
TL;DR: General population data from the National Comorbidity Survey are presented on co-occurring DSM-III-R addictive and mental disorders, with the finding that fewer than half of cases with 12-monthCo-occurrence received any treatment in the year prior to interview suggests the need for greater outreach efforts.
Abstract: General population data from the National Comorbidity Survey are presented on co-occurring DSM-III-R addictive and mental disorders. Co-occurrence is highly prevalent in the general population and usually due to the association of a primary mental disorder with a secondary addictive disorder. It is associated with a significantly increased probability of treatment, although the finding that fewer than half of cases with 12-month co-occurrence received any treatment in the year prior to interview suggests the need for greater outreach efforts.
1,424 citations
TL;DR: The Medical Outcomes Study was designed to determine whether variations in patient outcomes are explained by differences in system of care, clinician specialty, and clinicians' technical and interpersonal styles and develop more practical tools for the routine monitoring of patient outcomes in medical practice.
Abstract: The Medical Outcomes Study was designed to (1) determine whether variations in patient outcomes are explained by differences in system of care, clinician specialty, and clinicians' technical and interpersonal styles and (2) develop more practical tools for the routine monitoring of patient outcomes in medical practice. Outcomes included clinical end points; physical, social, and role functioning in everyday living; patients' perceptions of their general health and well-being; and satisfaction with treatment. Populations of clinicians (n = 523) were randomly sampled from different health care settings in Boston, Mass; Chicago, Ill; and Los Angeles, Calif. In the cross-sectional study, adult patients (n = 22 462) evaluated their health status and treatment. A sample of these patients (n = 2349) with diabetes, hypertension, coronary heart disease, and/or depression were selected for the longitudinal study. Their hospitalizations and other treatments were monitored and they periodically reported outcomes of care. At the beginning and end of the longitudinal study, Medical Outcomes Study staff performed physical examinations and laboratory tests. Results will be reported serially, primarily inThe Journal. (JAMA. 1989;262:925-930)
1,139 citations
TL;DR: This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.
Abstract: Objective. —Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers. Design. —Randomized controlled clinical trial with 12-month follow-up. Setting. —A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties. Participants. —Of the 17 695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures. Intervention. —The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information. Main Outcome Measures. —Alcohol use measures, emergency department visits, and hospital days. Results. —There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls;t=4.33;P Conclusions. —This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.
839 citations