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September 23, 2013

"More hands-on management of alcoholism does not guarantee abstinence"

Saitz and co-authors conducted a randomised trial among 563 people with alcohol and other drug dependence to investigate whether chronic care management improves substance use outcomes compared with usual primary care.

Fotolia_5603033_Scott MaxwellThe media headline above for the study in JAMA begged a few questions for clarification. Addiction Today posed three, kindly and promptly responded to by lead researcher Richard Saitz MD, MPH, FACP, FASAM, Professor of Medicine & Epidemiology and Director of the Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston University Schools of Medicine & Public Health.

Watch video.   Study.

1 Were participants assessed to differentiate between those who were addicted/dependent and those who were abusing substances?
Potential participants were all assessed to see if they met diagnostic criteria for alcohol or other drug dependence.  Only people who met criteria for DSM IV alcohol dependence or drug dependence were enrolled in the study.  People who had abuse and no dependence were not enrolled.

2 When patients were referred to outside services, were they assessed first, did they enter services, and what did these consist of?
All patients underwent extensive research assessments.  In the control group, patients were then given a state substance abuse hotline number and a primary care appointment and the number to access mutual help groups.  It was their choice to connect with those services and they did not receive further assessment from study personnel though the hotline would link patients with assessment and triage services or directly to programs that provide assessments.  Again, that was not part of the study. 

It is important to note that the study itself had no control over treatment options in the community, their quality or accessibility.  It was not a study of whether community treatment works.  It was a study of whether giving people a longitudinal relationship with a Chronic Care Management team to both treat them and help them link with services they needed and wanted that were available in the community was better than just letting people know treatment might be available by giving phone numbers and further primary care.

Patients assigned to the chronic care management group were all assessed by the clinical CCM team from an addictions, medical, other mental health and social services perspective.  They were reassessed when clinically indicated (for example, if their clinical status changed and they needed or wanted a referral).  It was then up to the patients (as it always is, of course) to choose to avail themselves of available and recommended services.  Twelve months later, participants in the CCM group reported use of services and other help as follows in the past 3 months:  54% had attended at least 1 mutual help meeting; 49% reported receiving addiction specialty care (treatment in the community like outpatient or inpatient counselling); 58% reported receiving addiction medications (eg buprenorphine, methadone, naltrexone, acamprosate, disulfiram).  Of note, people who were assigned to the CCM group were (based on statistics) significantly more likely to receive addiction specialty care and medications (though by very little—around 5% more) than those in the control group who were not assigned to CCM.  Detail is in Table 3 of the paper.

3 How long is the followup period (will you be following further)?
The follow-up period was a minimum of one year and the outcomes we assessed systematically were at a one year contact (note that the one year contact wasn’t exactly 365 days after study enrolment – there was a window during which follow-up could occur that extended to 18 months).  Although we do not plan to follow them up again in person or by phone, we do plan to obtain treatment utilization data from the state of Massachusetts that would extend follow-up on those outcomes (use of treatment services) by a great deal, to the present from 2006-2008 (so for the earliest people enrolled, to about 6 years). But those data will only include use of services, not clinical outcomes, and to date we have not been able to obtain them.  It is also noteworthy that we saw no benefits / differences at 3 months or 6 months.  While it is plausible that benefits could emerge after a year of CCM this seems unlikely, and even if true, doing CCM for a year or more and expecting to see benefit a few years later, would not likely be an attractive health policy option because of the short term costs.


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