Sunday, September 22, 2013

Do Addicts Benefit From Chronic Care Management?


Controversial JAMA study questions orthodox addiction treatment.

 What is the best way to treat addiction? The conventional wisdom has been to treat it with chronic care management (CCM), the same approach used for various medical and mental illnesses. But a study in the Journal of the American Medical Association (JAMA) purports to demonstrate that “persons with alcohol and other drug dependence who received chronic care management (CCM)” were no more likely to become abstinent that those who received nothing beyond a timely appointment with a primary care physician, and a list of addiction treatment resources.

563 patients were divided into a chronic care management group and a primary care group. The chronic care management group received extended care under a primary care physician, plus
“motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (to specialty addiction treatment mutual help.)” The primary care group got the aforementioned doctor’s appointment and printed list of treatment resources.

The study by researchers at Boston Medical Center found that “there was no significant difference in abstinence from opioids, stimulants, or heavy drinking between the CCM (44%) and control (42%) groups. No significant differences were found for secondary outcomes of addiction severity, health-related quality of life, or drug problems.”

But there are limitations. To wit:

1) Small sample size. 282 patients in a Boston Hospital’s chronic care management facility, and 281 participants farmed out to a primary care physician, is the total. Given the known failure rates for chronic care management as applied to smoking, diabetes, and mental illness, and variability in the counseling given the control group by individual physicians, 563 people isn’t really a sufficient cohort to be anything but suggestive. And, since many alcoholics and other drug addicts get sober by means of their own efforts, independent of formal medical intervention, percentage comparisons of such small groups are problematic in addiction studies.

2) Hard Core Cases Only. “Most study participants were dependent on both alcohol and other drugs, recruited from a detoxification unit, had substantial mental health symptoms had recently been homeless, and were not necessarily seeking addiction treatment,” according to the JAMA study. Okay, who might the findings not apply to? “Addiction treatment-seeking or less severely affected populations or to populations recruited elsewhere.”

3) Mostly self-reported data. The investigators assessed main outcomes by self-report. “Biological tests are inadequate for detecting substance use, particularly when it is not recent,” they explain. “Substance use problems and health-related quality of life are best assessed by self-report.” Outcomes were also based on self-reported 30-day abstinence.

4) Alcohol abusers did better under CCM. The research documented “a small effect on alcohol problems among those with dependence.” On alcoholics, in other words. “No subgroup effects were found except among those with alcohol dependence, in whom CCM was associated with fewer alcohol problems.” So CCM works, at least to a degree, for alcoholics, even in this study. Nonetheless, the study concludes: “CCM for substance dependence in primary care is not effective, at least not as implemented in this study and population.” (Note the caveats, and see #2 above)

5) Treatment fails for many reasons. One reason might be that the length of treatment was too short. According to the study, the intervention group “had, on average, 6 CCM visits….” Moreover, “the whole group improved over time; the change most likely was due to many participants having been enrolled at a detoxification unit….” The researchers also admit that “assessment effects in treatment trials are inconsistent and poorly understood and often absent in studies of people not seeking treatment.”

It may even be true that chronic care management, which seems so logical and successful an approach for everything from depression to smoking cessation, doesn’t work any better for drug addiction than a simple doctor’s visit and a handful of pamphlets. But this study doesn't clinch the case.

Graphics Credit: http://www.ihi.org

Saitz R. (2013). Chronic Care Management for Dependence on Alcohol and Other Drugs: The AHEAD Randomized Trial, JAMA, 310 (11) 1156. DOI:

1 comment:

Shannon Mauler said...

The study’s findings are interesting, however unclear as to what services those that did not receive CCM participated in. It would be interesting if the study divided by alcohol use disorder (AUD) and other substance abuse disorders. To ensure long-term recovery, AUD requires a comprehensive care plan including education, behavioral therapy, support groups, and in some cases pharmacology. Long-term recovery is dependent on the individual receiving treatment and relapse is normal in the recovery process (Treatment for Alcohol Problems: Finding and Getting Help). Providing nutritional, exercise, and meditation education in a comprehensive care plan provides the person with AUD valuable tools for a healthier life; these tools also lead to improvement in overall mood, increasing strength of coping skills, decreasing alcohol cravings and providing healthy alternatives to manage stress (Bowman, et al.; Linke and Ussher; Tang, et al.). Behavioral therapy such as Cognitive Behavioral Therapy (CBT) identifies what thoughts trigger the desire for alcohol and provides behavioral steps to allow those with AUD to build their coping skills to avoid alcohol in stressful situations (Treatment for Alcohol Problems: Finding and Getting Help 7). Family therapies may increase the strength support system needed for abstinence and long-term recovery (Treatment for Alcohol Problems: Finding and Getting Help 7). Support groups are widely accepted as effective in the AUD treatment plan, although by their anonymous nature data is difficult to validate the effectiveness (Brache; Witkiewitz). Incorporating the use of pharmaceuticals and pharmacology education in the care plan can achieve better outcomes (Seneviratne and Johnson; West Pines Behavioral Health). Using comprehensive care planning would treat the person with AUD holistically avoiding gaps in medical and behavioral treatment, providing a network of support for the person, focusing on overall health through wellness, all of which increase the odds of recovery.

Works Cited

Bowman, Stacy, et al. "Nutrition Education in Residential Alcohol Treatment Facilities." Journal of Alcohol & Drug Education, vol. 60, no. 3, Dec. 2016, pp. 7-15. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=120544423&site=ehost-live. Accessed 17 April 2017.
Brache, Kristina. "Advancing Interpersonal Therapy for Substance Use Disorders." American Journal of Drug & Alcohol Abuse, vol. 38, no. 4, July 2012, pp. 293-298. EBSCOhost, doi:10.3109/00952990.2011.643995. Accessed 19 April 2017.
Linke, Sarah E. and Michael Ussher. "Exercise-Based Treatments for Substance Use Disorders: Evidence, Theory, and Practicality." American Journal of Drug & Alcohol Abuse, vol. 41, no. 1, Jan. 2015, pp. 7-15. EBSCOhost, doi:10.3109/00952990.2014.976708. Accessed 19 April 2017.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). “Treatment for Alcohol Problems: Finding and Getting Help”. National Institutes of Health (NIH), February 2017, https://pubs.niaaa.nih.gov/publications/Treatment/treatment.pdf . Accessed 18 April 2017.
Seneviratne, Chamindi and Bankole A. Johnson. "Advances in Medications and Tailoring Treatment for Alcohol Use Disorder." Alcohol Research: Current Reviews, vol. 37, no. 1, Jan. 2015, pp. 15-28. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=108890036&site=ehost-live. Accessed 19 April 2017.
Witkiewitz, Katie, et al. "Religious Affiliation and Spiritual Practices: An Examination of the Role of Spirituality in Alcohol Use and Alcohol Use Disorder." Alcohol Research: Current Reviews, vol. 38, no. 1, Jan. 2016, pp. 55-58. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=115170581&site=ehost-live.
West Pines Behavioral Health. “Recovery Center”. SCL Health. 2017, http://www.westpinesrecovery.org/recovery-center/ . Accessed 18 April 2017.

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