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: 10.1001/jama.2013.277609

Heroin in Vietnam: The Robins Study Reexamined

How everything we knew about heroin was wrong.

Editor's note: The famous Robins study on heroin use among Vietnam veterans has been so often—and so recently—misinterpreted that I felt motivated to reprint an older post on the subject.

[Originally posted 7/24/10]

In 1971, under the direction of Dr. Jerome Jaffe of the Special Action Office on Drug Abuse Prevention, Dr. Lee Robins of Washington University in St. Louis undertook an investigation of heroin use among young American servicemen in Vietnam. Nothing about addiction research would ever be quite the same after the Robins study. The results of the Robins investigation turned the official story of heroin completely upside down.

The dirty secret that Robins laid bare was that a staggering number of Vietnam veterans were returning to the U.S. addicted to heroin and morphine. Sources were already reporting a huge trade in opium throughout the U.S. military in Southeast Asia, but it was all mostly rumor until Dr. Robins surveyed a representative sample of enlisted Army men who had left Vietnam in September of 1971—the date at which the U.S. Army began a policy of urine screening. The Robins team interviewed veterans within a year after their return, and again two years later. 

After she had worked up the interviews, Dr. Robins, who died in 2009, found that almost half—45 per cent—had used either opium or heroin at least once during their tour of duty. 11 per cent had tested positive for opiates on the way out of Vietnam. Overall, about 20 per cent reported that they had been addicted to heroin at some point during their term of service overseas.

To put it in the kindest possible light, military brass had vastly underestimated the problem. One out of every five soldiers in Vietnam had logged some time as a junky. As it turned out, soldiers under the age of 21 found it easier to score heroin than to hassle through the military’s alcohol restrictions. The “gateway drug hypothesis” didn’t seem to function overseas. In the United States, the typical progression was assumed to be from “soft” drugs (alcohol, cigarettes, and marijuana) to the “hard” category of cocaine, amphetamine, and heroin. In Vietnam, soldiers who drank heavily almost never used heroin, and the people who used heroin only rarely drank. The mystery of the gateway drug was revealed to be mostly a matter of choice and availability. One way or another, addicts found their way to the gate, and pushed on through. 

“Perhaps our most remarkable finding,” Robins later noted, “was that only 5% of the men who became addicted in Vietnam relapsed within 10 months after return, and only 12% relapsed even briefly within three years.” What accounted for this surprisingly high recovery rate from heroin, thought to be the most addictive drug of all? As is turned out, treatment and/or institutional rehabilitation didn’t make the difference: Heroin addiction treatment was close to nonexistent in the 1970s, anyway. “Most Vietnam addicts were not even detoxified while in service, and only a tiny percentage were treated after return,” Robins reported. It wasn’t solely a matter of easier access, either, since roughly half of those addicted in Vietnam had tried smack at least once after returning home. But very few of them stayed permanently readdicted.

Any way you looked at it, too many soldiers had become addicted, many more than the military brass had predicted. But somehow, the bulk of addicted soldiers toughed their way through it, without formal intervention, after they got home. Most of them kicked the habit. Even the good news, then, took some getting used to. The Robins Study painted a picture of a majority of soldiers kicking it on their own, without formal intervention. For some of them, kicking wasn’t even an issue. They could “chip” the drug at will—they could take it or leave it. And when they came home, they decided to leave it.

However, there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty. And when they did, they had a very strong tendency to relapse. Frequently, they could not shake it at all, and rarely could they shake it for good and forever. Readers old enough to remember Vietnam may have seen them at one time or another over the years, on the streets of American cities large and small. Until quite recently, only very seriously addicted people who happened to conflict with the law ended up in non-voluntary treatment programs.

The Robins Study sparked an aggressive public relations debate in the military. Almost half of America’s fighting men in Vietnam had evidently tried opium or heroin at least once, but if the Robins numbers were representative of the population at large, then relatively few people who tried opium or heroin faced any serious risk of long-term addiction. A relative small number of users were not so fortunate, as Robins noted. What was the difference?

Quotes from: Robins, Lee N. (1994). “Lessons from the Vietnam Heroin Experience.” Harvard Mental Health Letter. December.

See also:

Robins, Lee. N. (1993) “Vietnam veterans' rapid recovery from heroin addiction: a fluke or normal expectation?” Addiction. 88(8), 1037 – 1167.

Origins of the Disease Model of Addiction (Part 1) can be found HERE.

Photo Credit:  soldiersupportproject.org

They Inhaled

The "Nice People Take Drugs" campaign.

From the UK charity Release comes the project called Nice People Take Drugs. The publicity campaign has caused significant controversy in Britain, as reported by the UK Guardian. Release says on its web site that its charter is to "campaign for changes to UK drug policy to bring about a fairer and more compassionate legal framework to manage drug use in our society."

An earlier, similar campaign, using the same slogan and photos of well-known people on bus advertisements, ended when the bus company removed the ads, fearing a public backlash.