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!