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Journal ArticleDOI

Integrating primary medical care with addiction treatment: a randomized controlled trial.

10 Oct 2001-JAMA (American Medical Association)-Vol. 286, Iss: 14, pp 1715-1723
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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Journal ArticleDOI
TL;DR: It is concluded that neuroscience continues to support the brain disease model of addiction, which has led to the development of more effective methods of prevention and treatment and to more informed public health policies.
Abstract: This article reviews scientific advances in the prevention and treatment of substance-use disorder and related developments in public policy. In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned, perhaps because the aberrant, impulsive, and compulsive behaviors that are characteristic of addiction have not been clearly tied to neurobiology. Here we review recent advances in the neurobiology of addiction to clarify the link between addiction and brain function and to broaden the understanding of addiction as a brain disease. We review findings on the desensitization of reward circuits, which dampens the ability to feel pleasure and the motivation to pursue everyday activities; the increasing strength of conditioned responses and stress reactivity, which results in increased cravings for alcohol and other drugs and negative emotions when these cravings are not sated; and the weakening of the brain regions involved in executive functions such as decision making, inhibitory control, and self-regulation that leads to repeated relapse. We also review the ways in which social environments, developmental stages, and genetics are intimately linked to and influence vulnerability and recovery. We conclude that neuroscience continues to support the brain disease model of addiction. Neuroscience research in this area not only offers new opportunities for the prevention and treatment of substance addictions and related behavioral addictions (e.g., to food, sex, and gambling) but may also improve our understanding of the fundamental biologic processes involved in voluntary behavioral control. In the United States, 8 to 10% of people 12 years of age or older, or 20 to 22 million people, are addicted to alcohol or other drugs. 1 The abuse of tobacco, alcohol, and illicit drugs in the United States exacts more than $700 billion annually in costs related to crime, lost work productivity, and health care. 2-4 After centuries of efforts to reduce addiction and its related costs by punishing addictive behaviors failed to produce adequate results, recent basic and clinical research has provided clear evidence that addiction might be better considered and treated as an acquired disease of the brain (see Box 1 for definitions of substance-use disorder and addiction). Research guided by the brain disease model of addiction has led to the development of more effective methods of prevention and treatment and to more informed public health policies. Notable examples include the Mental Health Parity and Addiction Equity Act of 2008, which requires medical insurance plans to provide the same coverage for substance-use disorders and other mental illnesses that is provided for other illnesses, 5 and the proposed bipartisan Senate legislation that From the National Institute on Drug Abuse (N.D.V.) and the National Institute of Alcohol Abuse and Alcoholism (G.F.K.) — both in Bethesda, MD; and the Treatment Research Institute, Philadelphia (A.T.M.). Address reprint requests to Dr. Volkow at the National Institute on Drug Abuse, 6001 Executive Bld., Rm. 5274, Bethesda, MD 20892, or at nvolkow@ nida . nih . gov.

1,063 citations

01 Jan 2016
TL;DR: Volkow et al. as mentioned in this paper reviewed recent advances in the neurobiology of addiction to clarify the link between addiction and brain function and to broaden the understanding of addiction as a brain disease.
Abstract: This article reviews scientific advances in the prevention and treatment of substance-use disorder and related developments in public policy. In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned, perhaps because the aberrant, impulsive, and compulsive behaviors that are characteristic of addiction have not been clearly tied to neurobiology. Here we review recent advances in the neurobiology of addiction to clarify the link between addiction and brain function and to broaden the understanding of addiction as a brain disease. We review findings on the desensitization of reward circuits, which dampens the ability to feel pleasure and the motivation to pursue everyday activities; the increasing strength of conditioned responses and stress reactivity, which results in increased cravings for alcohol and other drugs and negative emotions when these cravings are not sated; and the weakening of the brain regions involved in executive functions such as decision making, inhibitory control, and self-regulation that leads to repeated relapse. We also review the ways in which social environments, developmental stages, and genetics are intimately linked to and influence vulnerability and recovery. We conclude that neuroscience continues to support the brain disease model of addiction. Neuroscience research in this area not only offers new opportunities for the prevention and treatment of substance addictions and related behavioral addictions (e.g., to food, sex, and gambling) but may also improve our understanding of the fundamental biologic processes involved in voluntary behavioral control. In the United States, 8 to 10% of people 12 years of age or older, or 20 to 22 million people, are addicted to alcohol or other drugs. 1 The abuse of tobacco, alcohol, and illicit drugs in the United States exacts more than $700 billion annually in costs related to crime, lost work productivity, and health care. 2-4 After centuries of efforts to reduce addiction and its related costs by punishing addictive behaviors failed to produce adequate results, recent basic and clinical research has provided clear evidence that addiction might be better considered and treated as an acquired disease of the brain (see Box 1 for definitions of substance-use disorder and addiction). Research guided by the brain disease model of addiction has led to the development of more effective methods of prevention and treatment and to more informed public health policies. Notable examples include the Mental Health Parity and Addiction Equity Act of 2008, which requires medical insurance plans to provide the same coverage for substance-use disorders and other mental illnesses that is provided for other illnesses, 5 and the proposed bipartisan Senate legislation that From the National Institute on Drug Abuse (N.D.V.) and the National Institute of Alcohol Abuse and Alcoholism (G.F.K.) — both in Bethesda, MD; and the Treatment Research Institute, Philadelphia (A.T.M.). Address reprint requests to Dr. Volkow at the National Institute on Drug Abuse, 6001 Executive Bld., Rm. 5274, Bethesda, MD 20892, or at nvolkow@ nida . nih . gov.

739 citations

01 Nov 2008
TL;DR: There is a reasonably strong body of evidence to encourage integrated care, at least for depression, and there is no discernible effect of integration level, processes of care, or combination on patient outcomes for mental health services in primary care settings.
Abstract: Objectives To describe models of integrated care used in the United States, assess how integration of mental health services into primary care settings or primary health care into specialty outpatient settings impacts patient outcomes and describe barriers to sustainable programs, use of health information technology (IT), and reimbursement structures of integrated care programs within the United States. Data sources MEDLINE, CINAHL, Cochrane databases, and PsychINFO databases, the internet, and expert consultants for relevant trials and other literature that does not traditionally appear in peer reviewed journals. Review methods Randomized controlled trials and high quality quasi-experimental design studies were reviewed for integrated care model design components. For trials of mental health services in primary care settings, levels of integration codes were constructed and assigned for provider integration, integrated processes of care, and their interaction. Forest plots of patient symptom severity, treatment response, and remission were constructed to examine associations between level of integration and outcomes. Results Integrated care programs have been tested for depression, anxiety, at-risk alcohol, and ADHD in primary care settings and for alcohol disorders and persons with severe mental illness in specialty care settings. Although most interventions in either setting are effective, there is no discernible effect of integration level, processes of care, or combination, on patient outcomes for mental health services in primary care settings. Organizational and financial barriers persist to successfully implement sustainable integrated care programs. Health IT remains a mostly undocumented but promising tool. No reimbursement system has been subjected to experiment; no evidence exists as to which reimbursement system may most effectively support integrated care. Case studies will add to our understanding of their implementation and sustainability. Conclusions In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention to mental health problems from the effects of specific strategies, evidenced by the lack of correlation between measures of integration or a systematic approach to care processes and the various outcomes. Efforts to implement integrated care will have to address financial barriers. There is a reasonably strong body of evidence to encourage integrated care, at least for depression. Encouragement can include removing obstacles, creating incentives, or mandating integrated care. Encouragement will likely differ between fee-for-service care and managed care. However, without evidence for a clearly superior model, there is legitimate reason to worry about premature orthodoxy.

420 citations


Cites background from "Integrating primary medical care wi..."

  • ...Hospitalacquired complications in a randomized controlled clinical trial of a geriatric consultation team JAMA 1987 May 1; 257(17):2313-7....

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  • ...2004 Sep 27;164(17):1839] Archives of Internal Medicine 2004 Jun 28; 164(12):1293-7....

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Journal ArticleDOI
TL;DR: The conceptual and practical importance of the ASI's multi-dimensional approach to measuring addiction severity, as illustrated by two case presentations, and how this measurement approach has led to some important findings regarding the prediction and measurement of addiction treatment effectiveness are reviewed.
Abstract: The Addiction Severity Index (ASI) is a multi-dimensional interview used to measure the substance use, health, and social problems of those with alcohol and other drug problems, both at admission to treatment and subsequently at follow-up contacts. This article first discusses the conceptual and practical importance of the ASI's multi-dimensional approach to measuring addiction severity, as illustrated by two case presentations. The second section of the paper reviews how this measurement approach has led to some important findings regarding the prediction and measurement of addiction treatment effectiveness. The third section describes the historical and practical considerations that have changed the instrument over time, details the problems with the instrument, and describes our efforts to correct those problems with the ASI-6. Finally, some recent ASI data collected from over 8,400 patients admitted to a nationally representative sample of U.S. addiction treatment programs are presented.

398 citations

DOI
01 Jan 2009
TL;DR: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Abstract: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. 1.Opioid-related disorders-drug therapy. 2.Opioid-related disorders-psychology. 3.Substance abuse-prevention and control. 4.

397 citations

References
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Journal ArticleDOI
TL;DR: This study examined the patient and treatment factors associated with 6-month outcome in 649 opiate-, alcohol-, and cocaine-dependent adults, treated in inpatient and outpatient settings, in 22 publicly and privately funded programs.
Abstract: This study examined the patient and treatment factors associated with 6-month outcome in 649 opiate-, alcohol-, and cocaine-dependent (male and female) adults, treated in inpatient and outpatient settings, in 22 publicly and privately funded programs. Outcomes were predicted by similar factors, regardless of the drug problem of the patient or the type of treatment setting or funding. Greater substance use at follow-up was predicted only by greater severity of alcohol and drug use at treatment admission, not by the number of services received during treatment. Better social adjustment at follow-up was negatively predicted by more severe psychiatric, employment, and family problems at admission and positively predicted by more psychiatric, family, employment, and medical services provided during treatment.

391 citations

Journal ArticleDOI
TL;DR: Given the potential benefits of creating tangible systems in which primary care, mental health, and substance abuse services are meaningfully linked, efforts to implement, examine, and measure the real impact should be a high priority.
Abstract: Individuals with alcohol and drug use problems may receive health care from medical, mental health, and substance abuse providers, or a combination of all three. Systems of care are often distinct and separate, and substantial opportunities for benefit to patient, provider, and payer are missed. In this article, we outline (1) the possible benefits of linking primary care, mental health, and substance abuse services from the perspective of the major stakeholders-medical and mental health providers, addiction clinicians, patients, and society-and (2) reasons for suboptimal linkage and opportunities for improving linkage within the current health care system. We also review published models of linked medical and substance abuse services. Given the potential benefits of creating tangible systems in which primary care, mental health, and substance abuse services are meaningfully linked, efforts to implement, examine, and measure the real impact should be a high priority.

227 citations

Journal ArticleDOI
TL;DR: Providing medical care at a methadone treatment program site is more effective than the usual referral procedure and is a valuable public health intervention.
Abstract: OBJECTIVES. Intravenous drug users are at high risk for medical illness, yet many are medically underserved. Most methadone treatment programs have insufficient resources to provide medical care. The purpose of this study was to test the efficacy of providing medical care at a methadone clinic site vs referral to another site. METHODS. Patients with any of four target medical conditions were randomized into an on-site group offered medical care at the methadone treatment clinic and a referred group offered medical care at a nearby clinic. Entry to treatment and use of medical services were analyzed. RESULTS. Of 161 intravenous drug users evaluated, 75 (47%) had one or more of the target medical conditions. Fifty-one were randomized. In the on-site group (n = 25), 92% received medical treatment; in the referred group (n = 26), only 35% received treatment. CONCLUSIONS. Providing medical care at a methadone treatment program site is more effective than the usual referral procedure and is a valuable public he...

181 citations

Trending Questions (2)
How much do substance abuse doctors make?

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.

Which type of facility is best for treating patient suffering with substance abuse?

CONTEXT The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment.