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: The findings suggest that a low-risk drinking outcome may be reasonable over the long-term for some alcohol-dependent individuals receiving addiction treatment.
Abstract: Author(s): Kline-Simon, Andrea H; Litten, Raye Z; Weisner, Constance M; Falk, Daniel E | Abstract: BackgroundTreatment for alcohol use disorders (AUDs) has traditionally been abstinence oriented, but new research and regulatory guidelines suggest that low-risk drinking may also be an acceptable treatment outcome. However, little is known about long-term outcomes for patients who become low-risk drinkers posttreatment. This study explores a posttreatment low-risk drinking outcome as a predictor of future drinking and psychosocial outcomes over 9 years.MethodsStudy participants were adults with AUDs at treatment entry who received follow-up interviews 6 months posttreatment intake (N = 1,061) in 2 large randomized studies conducted at Kaiser Permanente Northern California, a large private, nonprofit, integrated health system. Six-month drinking status was defined as abstinent, low-risk (nonabstinent, no 5+ drinking days), or heavy drinking (1 or more days of 5+ drinks). Using logistic regression models, we explored the relationship between past 30-day drinking status at 6 months and odds of being abstinent or a low-risk drinker (compared to heavy drinking), and positive Addiction Severity Index psychosocial outcomes over 9 years (9-year follow-up rate of 73%).ResultsAbstainers and low-risk drinkers at 6 months had higher odds of recent abstinence/low-risk drinking over 9 years than heavy drinkers; abstainers had better drinking outcomes than low-risk drinkers. Additionally, among those with interview data, 95% of abstainers and 94% of low-risk drinkers at 6 months were abstinent/low-risk drinkers at 9 years; surprisingly, 89% of heavy drinkers at 6 months were also abstinent/low-risk drinkers although still significantly fewer than the other groups. Abstainers and low-risk drinkers at 6 months had better psychiatric outcomes, and abstainers had better family/social outcomes than heavy drinkers; medical outcomes did not differ. Low-risk drinkers and abstainers showed no reliable differences across psychosocial measures.ConclusionsThe findings suggest that a low-risk drinking outcome may be reasonable over the long-term for some alcohol-dependent individuals receiving addiction treatment.
27 citations
TL;DR: Patients’ positive perceptions of their alliance with their clinician and their satisfaction with treatment was significantly associated with more days of abstinence from alcohol during treatment, and clinician confidence in the Medical Management treatment and flexibility in delivering Medical Management were associated with better patient outcomes.
Abstract: PURPOSE Alcohol dependence, frequently seen in medical settings, is a major problem that affects the health and well-being of many individuals and their families. The purpose of this study was to examine the relationship between treatment outcomes and patient and clinician factors specifically associated with a medically oriented intervention given for the treatment of alcohol dependence. The intervention was developed for the National Institute on Alcohol Abuse and Alcoholism–sponsored COMBINE Study, a randomized controlled trial combining 2 medications, naltrexone and acamprosate, with Medical Management, with or without specialty alcohol treatment.
METHODS We examined the effect of patient adherence to treatment (number of Medical Management visits, total minutes in treatment, alliance or therapeutic relationship with the clinician, patient satisfaction with treatment, and clinician adherence to the Medical Management protocol) on abstinence from alcohol, amount of heavy drinking, and clinical improvement during treatment.
RESULTS More Medical Management visits attended and less total time spent in Medical Management treatment was associated with more days of abstinence from alcohol, reductions in heavy alcohol drinking, and a higher likelihood of clinical improvement. The patients’ positive perceptions of their alliance with their clinician and their satisfaction with treatment was significantly associated with more days of abstinence from alcohol during treatment. Two clinician factors clinician confidence in the Medical Management treatment and flexibility in delivering Medical Management were also associated with better patient outcomes.
CONCLUSIONS Medically trained clinicians with minimal specialty training in alcohol dependence treatments were able to deliver a brief and effective medication management intervention that was designed to be consistent with primary care practice.
27 citations
Cites background from "Integrating primary medical care wi..."
...of essential elements of the Medical Management intervention (protocol); (2) no deviations from the protocol (strict adherence); (3) conveying professionalism, expertise, and confi dence in treatment (authoritative); (4) communicating correct educational information in a clear and concise manner (informative); (5) being warm, friendly, compassionate, helpful, and concerned (warmth); and (6) providing structure, coherence, and fl ow to the visit (direction)....
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TL;DR: Combinations of medical and behavioral interventions should be used to promote persons with substance use disorders engagement into and adherence with direct-acting antiviral-based treatment approaches, which have the potential to improve adherence and consequently treatment efficacy.
Abstract: Direct-acting antivirals for hepatitis C virus infection may revolutionize treatment among persons with substance use disorders. Despite persons with substance use disorders having the highest hepatitis C virus prevalence and incidence, the vast majority have not engaged into care for the infection. Previously, interferon-based treatments, with substantial side effects and the propensity to exacerbate mental health conditions, were major disincentives to pursuit of care for the infection. Direct-acting antivirals with viral eradication rates of >90%, significantly improved side effect profiles, and shorter treatment duration are dramatic improvements over prior treatment regimens that should promote widespread hepatitis C virus care among persons with substance use disorders. The major unmet need is strategies to promote persons with substance use disorders engagement into care for hepatitis C virus. Although physical integration of treatment for substance use and co-occurring conditions has been widely advocated, it has been difficult to achieve. Telemedicine offers an opportunity for virtual integration of behavioral and medical treatments that could be supplemented by conventional interventions such as hepatitis C virus education, case management, and peer navigation. Furthermore, harm reduction and strategies to reduce viral transmission are important to cease reinfection among persons with substance use disorders. Widespread prescription of therapy for hepatitis C virus infection to substance users will be required to achieve the ultimate goal of global virus elimination. Combinations of medical and behavioral interventions should be used to promote persons with substance use disorders engagement into and adherence with direct-acting antiviral-based treatment approaches. Ultimately, either physical or virtual colocation of hepatitis C virus and substance use treatment has the potential to improve adherence and consequently treatment efficacy.
27 citations
Cites background from "Integrating primary medical care wi..."
...on Pursuit of Hepatitis C Virus Treatment Engagement in treatment of addiction and integration with primary medical care has been shown to be costeffective, to improve medical outcomes, and to result in decreased numbers of hospitalizations.(107,108) Treatment of addiction may have other health benefits from a psychosocial perspective....
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TL;DR: Investigation of substance abuse/dependence subtypes in a diverse low-income welfare to work sample and subtype differences in rates of comorbid psychiatric and medical conditions revealed several between-class differences, perhaps reflecting differing levels of severity and service needs.
26 citations
TL;DR: Results of multivariate logistic generalized estimating equation models find an association between psychiatric trajectories and long-term SU.
Abstract: This study identifies longitudinal psychiatric trajectories of 934 adult individuals entering chemical dependency treatment in a private, managed care health plan and examines the relationship of these trajectories with substance use (SU) outcomes. The authors apply a group-based modeling approach to identify trajectory groups based on repeated measures of psychiatric severity for 9 years and identify four distinct groups. Results of multivariate logistic generalized estimating equation models find an association between psychiatric trajectories and long-term SU. Older cohorts and life course measures of marital status and employment status as individuals changed over time are related to drug and some alcohol outcomes.
26 citations
Cites background from "Integrating primary medical care wi..."
..., text revision; DSM-IVTR; American Psychiatric Association 2000) to provide a DSM-IV-TR diagnosis for alcohol and drug (11 substance types) dependence and abuse (Caetano and Raspberry 2000; Ray, Weisner, and Mertens 2005; Weisner et al. 2001; Weisner et al. 2000; Weisner et al. 2003)....
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...…(4th ed., text revision; DSM-IVTR; American Psychiatric Association 2000) to provide a DSM-IV-TR diagnosis for alcohol and drug (11 substance types) dependence and abuse (Caetano and Raspberry 2000; Ray, Weisner, and Mertens 2005; Weisner et al. 2001; Weisner et al. 2000; Weisner et al. 2003)....
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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