6 sessions of chronic care management for addiction is not effective

evidenceJAMA published a study of a primary-care based chronic care management model (CCM) for addiction. The test group did no better than the control group.

The headline is a big bummer for any of us who want to see chronic disease models developed and implemented for addiction. What should we make of it?

Many headlines suggested that chronic care management for addiction doesn’t work.

A prominent writer described the model as “exquisitely tailored” and went further, stating that CCM didn’t work and the real problem is a lack of good treatments for addiction.

Are these fair representations?

Bill White emphasizes that this was NOT a study of recovery management. (Recovery Management is the chronic care management approach that he has advocated. It is the most frequently discussed chronic care model. Adaptations of it are being are being implemented across the country.)

Bill points out that there are important differences between the approach that was used and Recovery Management (RM). Those differences include:

  1. The service setting was a primary care clinic, a setting that it would make it challenging to establish a culture of recovery that kindles hope, normalizes long-term recovery.
  2. The treatment staff “consisted primarily of a nurse care manager and a social worker, with consultations available from internists and an addiction psychiatrist. Conspicuously absent from this list and key members of RM support teams are peer-recovery support specialists (e.g., recovery coaches), volunteers and alumni who are in recovery, and culturally indigenous healers.
  3. The core ingredients of the model did not include many elements of RM, including a focus on recovery capital, patient-developed recovery plans; assertive engagement of family and extended family; peer-based recovery coaching, service thresholds of at least 90 days, extending service delivery into the natural environment of the patient/family;  mobilization of indigenous recovery support resourcesassertive linkage to recovery mutual aid groups; and long term monitoring and support and early re-engagement and recovery re-stabilization.
  4. The duration of the intervention was one year, not the five year window that Bill has advocated.

Over at Addiction Inbox, Dirk Hanson had another important observation. He noted that the patients had an average of 6 visits.

When I looked for those details in the original article, here’s what I found:

Of the 282 participants assigned to the intervention group, 281 (99.6%) attended at least 1 CCM clinic visit, 75.9% attended at least 2, and 64.5% attended 3 or more visits (median, 6 visits; interquartile range, 2-16 visits). Most reported scores consistent with receipt of high-quality CCM at 12 months (75% had scores ≥3.3 on a scale adapted to assess addiction CCM; possible range, 1-5).37Most (62%) received 1 or more motivational enhancement therapy sessions and 27% completed 4 sessions.

Here’s the more detailed description of the model they used:

Intervention participants were asked to attend 2 AHEAD clinic visits (90 minutes each), separated by 3 to 4 days, receiving substance use, psychiatric, medical, and social assessments by all 4 clinicians. The main focus of these visits was to engage participants so they would return for ongoing care. Treatments for addiction and for medical and psychiatric conditions were begun depending on participants’ diagnoses and readiness/priorities. Clinicians were provided with the CIDI-SF and 9-item Patient Health Questionnaire results but no other research assessment results. Participants were escorted to their first visit as soon as possible after randomization. Participants were offered 4 sessions of motivational enhancement therapy with a social worker (who used the Mini-Mental State Examination, SIP, and liver enzyme measurements for patient feedback),32 relapse prevention counseling at every contact by whichever clinician they saw, usually the NCM or social worker (which includes assessment of substance use),33 a primary care appointment, and referral to specialty addiction treatment and mutual help groups, all tailored to clinical needs and patient preferences. Addiction pharmacotherapy (naltrexone, acamprosate, disulfiram, buprenorphine, and referral for methadone) and psychopharmacotherapy were offered as appropriate.

To me, the real question is, why would anyone think this would be an effective intervention for people that were not even seeking treatment? (The fact that the subjects were not seeking treatment has not gotten the notice it deserves.)

So, what conclusions can we draw? That a model that is primary care based, low-intensity, relatively passive, is not linked to communities of recovery and only manages to deliver an average of 6 sessions over the course of a year,  is not effective for people with relatively severe dependence who are not seeking treatment.

Why do knowledgeable reporters frame it as evidence that treatment is ineffective? Especially when the researchers, themselves, said, “Among people with addictions seeking treatment, favorable outcomes are already good without CCM”? It’s hard to understand, isn’t it?

Thanks to Bill White and Dirk Hanson for digging a little deeper and setting the record straight!

 

2 Comments

Filed under Controversies, Policy, Research, Treatment

2 responses to “6 sessions of chronic care management for addiction is not effective

  1. I actually agree with their results which stated:
    “There was no significant difference in abstinence from opioids, stimulants, or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds ratio, 0.84; 95% CI, 0.65-1.10; P=.21). No significant differences were found for secondary outcomes of addiction severity, health-related quality of life, or drug problems.”
    What they did not highlight was the significant improvement (over 50%) in rates of alcohol and drug use, homelessness, depression scores, risky sexual behavior, overdoses, etc. in BOTH study groups. (see table 1)

    I think that their conclusion is incorrect ”This study did not find an effect of CCM for substance dependence
    on substance use, related consequences (with the exception of a small effect on alcohol problems among those with
    dependence), health-related quality of life, or acute health care utilization.”

    The study actually showed great improvement in pts after 12 months of followup.
    What the study DID show that was unexpected was no significant difference in outcomes between pts offered services through a multidisciplinary substance abuse program compared to routine followup through their PCP.

    I would see this as offering two possibilities: either the AHEAD program was inadequate, or the PCPs provided treatment and referrals that was better than expected.

    Some limitations of the study:
    1. only studied dependence on alcohol, stimulants and opioids, not benzos, MJ or any others.
    2. they compared outcomes status based on number of visits to CCM but not for visits to PCP
    3. Neither study group had significant regular attendance at twelve-step groups.
    4. The patients assigned to the AHEAD clinic do not seem to have received really received “chronic care”, they only had 2-3 “engagement” sessions and 2-3 MET sessions, then given a phone number to call as needed.
    5. Although they were very proud of how “Chronic care management has been described as including
    6 elements, all of which are represented in the AHEAD clinic and are elements in which staff were trained:
    use of community resources, making the chronic illness and its management the priority, self-management support, delivery system design, decision support, and use of clinical information systems,” They did not measure or comment on how many of these elements were available to the patients through their PCP.