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Question
Question: Does chronic care management (CCM) improve substance use outcomes compared with usual primary care among people with alcohol and other substance dependence?
Patients: 563 adults (aged over 18 years) with a diagnosis of alcohol or other substance dependence. Alcohol dependence was assessed using the Composite International Diagnostic Interview Short Form (CIDI-SF), with heavy drinking in the past 30 days defined as ≥5 drinks on one occasion at least twice per week or ≥22 drinks per average week in men (≥4 and ≥15 drinks, respectively, in women). Substance dependence was also assessed using the CIDI-SF, and included use of psychostimulants (cocaine, methamphetamine or prescription amphetamine), heroin or prescription opioids, with misuse defined as use without a prescription, or in larger amounts or for longer duration than prescribed.
Setting: A hospital-based primary care practice in Boston, USA from 2006 to 2009.
Intervention: CCM versus control of a primary care appointment with no CCM. CCM consisted of longitudinal care coordinated with a primary care physician; motivational enhancement therapy; relapse prevention counselling; medical, addiction and psychiatric treatment; social work assistance and referrals. The control group received an appointment and given a list of resources including telephone numbers for counselling support.
Outcomes: Self-reported 30-day abstinence from heavy drinking, opioids or stimulants. Subgroup analysis by dependency type was conducted.
Patient follow-up: 98% of patients attended at least one follow-up interview (no significant difference between the groups).
Methods
Design: Randomised controlled trial.
Allocation: Not reported.
Blinding: Not reported.
Follow-up period: One year.
Main results
At 12 months there were no significant differences between the CCM and usual primary care group in terms of self-reported 30-day abstinence from heavy drinking opioids and stimulants (44% vs 42%, respectively; OR 0.84, 95% CI 0.65 to 1.10). Subgroup analysis by dependency type found no significant difference in either heavy drinking abstinence among 409 participants with alcohol dependency (55% vs 50%; OR 1.05, 95% CI 0.78 to 1.43), or stimulant and opioid abstinence among 458 participants with substance dependency (52% vs 51%; OR 0.85, 95% CI 0.64 to 1.14). Among 364 participants with substance dependence and recent stimulant use, there was no significant difference in stimulant abstinence at follow-up (51% vs 55%; OR 0.77, 95% CI 0.56 to 1.07). Among 369 participants with substance dependence and recent opioid use, there was a significant reduction in 30-day abstinence (52% vs 54%; OR 0.71, 95% CI 0.51 to 0.98).
Conclusions
CCM is no more effective than usual primary care at improving alcohol or other substance use among people with alcohol or substance dependency.
Notes
Participants were compensated for participation: US$35 at baseline, US$50 at month 3, US$50 at month6, US$75 at month 12. Only US$2 was given each time they updated their contact information, and a meal and transport reimbursement were offered at each study visit.
Abstracted from
Commentary
A spectrum of severity exists among people with substance use disorders. Only a minority have severe, recurrent symptoms. In this study, Saitz and colleagues examined chronic care management (CCM) in primary care for a severely affected group of patients either admitted to a detoxification centre (about 75%) or referred to the study. Many were homeless, about 80% had been incarcerated, while about half had injected drugs in the previous 3 months. The investigators found no effect from the CCM intervention, compared with a control group referred for usual care. However, there were substantial reductions in substance use and consequences 1 year later, especially in those with alcohol use disorder.
How do we make sense of these findings? First, this was not a treatment-seeking population. Most studies of treatment effectiveness recruit people who wish to change. Second, there were likely few external motivating factors, such as coercion from the justice system, an employer or family members. Third, although many participants had psychological symptoms, few were seriously medically ill; severe illness is another motivator for change. Although no data are presented concerning what treatments were received, it appears that most only received a few sessions of motivational interviewing, a weak intervention among people not already motivated to change.
The ‘take-away’ message might be: treatment, even when provided in a chronic care model, is only effective when an individual is motivated to change and willing to adhere to treatment recommendations. Also, non-treatment factors, especially social control, social support and socioeconomic factors are likely responsible for more change than most treatments. Our understanding of the change process is very limited. Improvement in outcomes will require research into how and why people change their health behaviours. In the mean time, it is important not to generalise the findings from this study to people with a better prognosis, as care management might work very well with less severely disadvantaged groups.
Footnotes
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Sources of funding: National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.
Footnotes
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Competing interests None.