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

Searching for Addiction Rehab

The perils of online rehab finders.

CALL NOW FOR HELP, say the sites designed to assist people in locating addiction treatment services in their area. But when you call that 800 number to speak to a “rehab counselor,” chances are you end up getting a sales pitch for a specific for-profit chain of rehab centers, rather than an objective survey of all available resources and how they might fit your personal needs.

Perhaps it’s not surprising that the simple act of reaching out for help, for pertinent resources, is sometimes perilous online. Everybody’s got something to sell, it seems. Few sites offer objective information in detail, without special pleading of one sort or another.  Even Scientology, working under the alias of Narconon, has its own rehab register, featuring the 120 drug and alcohol centers operated according to the principles of that well-known expert on drug and alcohol problems, L. Ron Hubbard.

One workaround is to stick with government sources. The Substance Abuse and Mental Health Services Administration (SAMSHA) has a decent one HERE.  But even government rehab finding pages are one-size-fits-all affairs, and sometimes suffer from a lack of regular updating.

Recently, the All About Addiction (A3)  website has rolled out a new rehab finder with some nice features that should go a long way toward filling the gap. Adi Jaffe, the site’s director and the motivating force behind the creation of the new rehab finder, is working on his PhD in Psychology at UCLA.  Jaffe’s original idea for a call center gradually morphed into a plan for an online tool. In an interview with Addiction Inbox, Jaffe expanded on the rationale for putting together a rehab finder he believes addresses some of the shortcomings found on other sites:

 “I decided to put together the rehab finder because I thought it was sad that with all the technology we have, the best way to find treatment was either to do a general Google search (cue paid ads by providers that charge a lot and can therefore pay for advertising) that results in lists upon lists of providers, or go the SAMHSA treatment locator, which only searches by location,” Jaffe explained in an email exchange. “I thought we could do better. I believe that if we can make it easier for people to find the right treatment we will increase enrollment in treatment because people will find treatment they can afford, and improve treatment outcomes because the treatment-client fit will improve.”

A further refinement is represented by a 20-question survey.  Questions about gender, employment status, health insurance, and mental health are designed to narrow the field of pertinent recommendations. Detailed questions about drug use, including amount spent per month, are also included. What the new rehab finder does NOT ask for is your name, your phone number, or your e-mail address, as other such sites commonly do. So there is no danger of follow-up sales calls or spam.

“For the most part, we don’t match people based on the treatment approach (CBT, MI, 12 step, or others), that’s been tried and failed – there seems to be little difference and we don’t know how to match there yet,” Jaffe said. “What we do is match on gender, age, insurance, mental health status, specific addiction specialty, and other factors like the need for detox, or specific treatments for specific drugs (like buprenorphine for heroin).”

Jaffe is now seeking funds for a study of the new finder’s effectiveness.  “I’d like to set up a few different versions (including a location-only search like SAMHSA’s) and see if our version works better,” he said. “It also lends itself to constant improvement based on the actual results obtained.”

As the A3 site says: Rehab is hard. Finding it shouldn’t be.

Graphics Credit: http://www.gentiva.com/

Friday File

Book and Blog Recommendations

Books

Garrison Keillor, my state’s answer to Mark Twain, often used a signature phrase on his radio show: “Be well, do good work, and keep in touch.” Michael S. Gazzaniga, brain scientist extraordinaire, says that this simple statement explains the essential difference between the cognitive complexity of humans and that of other primates. Put simply, “Other apes don’t have that sentiment.”

A cognitive neuroscientist at the University of California–Santa Barbara, Gazzaniga’s recent book, Human: The Science Behind What Makes Us Unique, looks at how we diverged from our ancestors to become sentient human beings. Hint: It has less to do with tool use and opposable thumbs than you might expect.

Gazzaniga wears his learning lightly and puts forth his ideas in an easy-going style. Though he does not mention them by name, he could have been thinking about PETA when he poses the ultimate question: “Would a chimp make a good date?”

Blogs

Neuroanthropology, a site dedicated to the “greater understanding of the encultured brain and body,” is another interdisciplinary gem of a blog.

In their own words, Neuroanthropology is a “collaborative weblog created to encourage exchanges among anthropology, philosophy, social theory, and the brain sciences. We especially hope to explore the implications of new findings in the neurosciences for our understanding of culture, human development, and behaviour.”

As part of that eclectic mix, Daniel Lende keeps a keen eye on the biology of drugs and alcohol, with a particular emphasis on “biopsychosocial” approaches to addiction.

Some of Neuroanthropology’s more popular posts include “Cultural Aspects of Post-Traumatic Stress Disorder,” “Sarah Palin and Language,” “Studying Sin,” and “How Your Brain is Not Like a Computer.” The site also features a great page of Web Resources.