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: There is strong evidence to support inequalities in medical care disadvantaging those who have a psychiatric illness or a substance use disorder.
Abstract: Background
There has been long-standing concern about the quality of medical care offered to people with mental illness.
Aims
To investigate whether the quality of medical care received by people with mental health conditions, including substance misuse, differs from the care received by people who have no comparable mental disorder.
Method
A systematic review of studies that examined the quality of medical care in those with and without mental illness was conducted using robust critical appraisal techniques.
Results
Of 31 valid studies, 27 examined receipt of medical care in those with and without mental illness and 10 examined medical care in those with and without substance use disorder (or dual diagnosis). Nineteen of 27 and 10 of 10, respectively, suggested inferior quality of care in at least one domain. Twelve studies found no appreciable differences in care or failed to detect a difference in at least one key area. Several studies showed an increase in healthcare utilisation but without any increase in quality. Three studies found superior care for individuals with mental illness in specific subdomains. There was inadequate information concerning patient satisfaction and structural differences in healthcare delivery. There was also inadequate separation of delivery of care from uptake in care on which to base causal explanations.
Conclusions
Despite similar or more frequent medical contacts, there are often disparities in the physical healthcare delivered to those with psychiatric illness although the magnitude of this effect varies considerably.
299 citations
TL;DR: The number of adults aged 50 or older with substance use disorder in the United States is projected to double from 2.8 million (annual average) in 2002-06 to 5.7 million in 2020, due to the large population size and high substance use rate of the baby-boom cohort.
Abstract: Aims This study aimed to project the number of people aged 50 years or older with substance use disorder (alcohol/ illicit drug dependence or abuse) in the United States in 2020. Design Logistic regression models were applied to estimate parameters predicting past-year substance use disorder using the 2002–06 National Survey on Drug Use and Health data. We applied these parameters to the projected US 2020 population to estimate the number of adults aged 50 or older with substance use disorder in 2020. Setting Non-institutionalized US residences. Participants Representative sample of the US civilian, non-institutionalized population. Measurements Substance use disorder is classified based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Findings Due to the large population size and high substance use rate of the baby-boom cohort, the number of adults aged 50 or older with substance use disorder is projected to double from 2.8 million (annual average) in 2002–06 to 5.7 million in 2020. Increases are projected for all examined gender, race/ethnicity and age groups. Conclusions Our estimates provide critical information for policymakers to allocate resources and develop prevention and treatment approaches to address future needs of the US older adult population with substance use disorder.
284 citations
Journal Article•
TL;DR: A body of experimental literature evaluating the impact of enhanced collaboration on patient outcomes-primarily in depressive disorders-now exists and better practices in collaborative mental health care are beginning to emerge.
Abstract: Objectives To conduct a systematic review of the experimental literature in order to identify better practices in collaborative mental health care in the primary care setting. Methods A review of Canadian and international literature using Medline, PsycInfo, Embase, the Cochrane Library, and other databases yielded over 900 related reports, of which, 38 studies met the inclusion criteria. A systematic review and descriptive analysis is presented, with key conclusions and best practices. Results Successful collaboration requires preparation, time, and supportive structures, building on preexisting clinical relationships. Collaborative practice is likely to be most developed when clinicians are colocated and most effective when the location is familiar and nonstigmatizing for patients. Degree of collaboration does not appear to predict clinical outcome. Enhanced collaboration paired with treatment guidelines or protocols offers important benefits over either intervention alone in major depression. Systematic follow-up was a powerful predictor of positive outcome in collaborative care for depression. A clear relation between collaborative efforts to increase medication adherence and clinical outcomes was not evident. Collaboration alone has not been shown to produce skill transfer in PCP knowledge or behaviours in the treatment of depression. Service restructuring designed to support changes in practice patterns of primary health care providers is also required. Enhanced patient education was part of many studies with good outcomes. Education was generally provided by someone other than the PCP. Collaborative interventions that are part of a research protocol may be difficult to sustain long-term without ongoing funding. Consumer choice about treatment modality may be important in treatment engagement in collaborative care (for example, having the option to choose psychotherapy vs medication). Conclusions A body of experimental literature evaluating the impact of enhanced collaboration on patient outcomes-primarily in depressive disorders-now exists. Better practices in collaborative mental health care are beginning to emerge.
272 citations
TL;DR: Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening and these results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention.
Abstract: Importance The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy. Objective To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)—a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)—compared with no brief intervention. Design, Setting, and Participants This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of ≥4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts. Interventions Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master’s-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources. Main Outcomes and Measures Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization. Results At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity. Conclusions and Relevance Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention. Trial Registration clinicaltrials.gov Identifier:NCT00876941
266 citations
TL;DR: Advances in addiction research are highlighted that, if disseminated to the public, could reverse misconceptions and facilitate changes in policy to improve treatment access and care delivery for this highly prevalent disease.
Abstract: In the United States, efforts to treat addiction are hampered by prejudice and a public view that treats it as a disorder of self-control, not a disease. We highlight select advances in addiction research that, if disseminated to the public, could reverse these misconceptions and facilitate changes in policy to improve treatment access and care delivery for this highly prevalent disease.
260 citations
References
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Book•
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