For substance abuse, chronic care management no better than usual care

Persons with substance abuse problems who received chronic care management, including relapse prevention counseling and medical, addiction and psychiatric treatment, were no more abstinent than those who received usual primary care, a study found.

Researchers recruited 563 adult participants between September 2006 and September 2008 from a freestanding residential detoxification unit, from referrals to an urban teaching hospital and from advertisements. Alcohol dependence was determined by the Composite International Diagnostic Interview Short Form (CIDI-SF) and was defined as heavy drinking in the past 30 days (for men, 5 or more drinks on 1 occasion at least twice or 22 or more drinks per week in an average week; for women, 4 or more drinks on 1 occasion at least twice or 15 or more drinks per week). Drug dependence was defined based on the CIDI-SF and past 30-day misuse of cocaine, methamphetamine, or prescription amphetamines, or use of heroin or prescription opioids, the latter without a prescription, in larger amounts than prescribed, or for a longer period than prescribed.

Participants were randomized 1:1 to chronic care management or a control group. The chronic care management group received coordinated care from a primary care clinician, motivational enhancement therapy and relapse prevention counseling, as well as on-site medical, addiction, and psychiatric treatment, social work assistance and referrals to specialty addiction treatment and mutual help. The control group received a timely appointment and a list of addiction treatment resources, including a telephone number to arrange counseling.

Results appeared in the Sept. 18 JAMA.

At 12 months, researchers found no difference in abstinence from stimulants, opioids and heavy drinking between the care management and control groups (44% vs. 42%; adjusted odds ratio [OR], 0.84; 95% CI, 0.65 to 1.10; P=0.21). There were no significant differences over time in the alcohol and drug dependence subgroups except for fewer alcohol problems in the intervention group among those with alcohol dependence (mean score, 10.4 vs. 13.1 at 12 months; incidence rate ratio [IRR], 0.85; 95% CI, 0.72 to 1.00; P=0.048).

Among 369 patients with drug dependence and recent use of opioids, at 12 months the intervention was associated with a lower odds of opioid abstinence throughout follow-up (52% vs. 54%; OR, 0.71; 95% CI, 0.51 to 0.98) and had no effect on days of opioid use (mean, 16.7 vs. 14.0 days; IRR, 1.19; 95% CI, 0.94 to 1.52 in an analysis adjusted for baseline use). Among 364 patients with drug dependence and recent use of stimulants, at 12 months there were no significant intervention effects on stimulant abstinence (51% vs. 55%; OR, 0.77; 95% CI, 0.56 to 1.07) or days of stimulant use (mean, 11.0 vs. 12.4 days; IRR, 1.05; 95% CI, 0.81 to 1.37 in an analysis adjusted for baseline use). The authors did not detect differences in secondary outcomes of addiction severity, health-related quality of life, or drug problems.

The researchers noted that health care reforms in the U.S. include a focus on chronic care management in patient-centered medical homes. They wrote, “Even though CCM [chronic care management] is effective for a number of chronic conditions, it may be premature to assume that CCM will be the solution to improve the quality of care for and reduce costs of patients with addiction.”

An accompanying editorial noted that the negative results provided a reason for future research. The study population, three-quarters of whom came from a detoxification unit and two-thirds of whom were addicted to more than 1 substance, had significant psychiatric and medical comorbidity and sometimes faced homelessness and incarceration. The editorialist wrote that a study focusing on patients who have either alcohol or drug dependence (but not both) might find different results.