Chronic care management does not result in increased abstinence from alcohol

Persons with alcohol and other drug dependence 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, according to a study in the September 18 issue of JAMA.

Chronic care management (CCM) is a way of delivering care that has been shown to be effective for chronic medical and mental health conditions. "Chronic care management is multidisciplinary patient-centered proactive care, a way to organize services that provides coordination and expertise, and has been effective for depression, medical illnesses, and tobacco dependence (a substance use disorder)," the authors write. Trials of integrated medical and addiction care suggest that CCM may be effective for treating addiction, particularly since care elements long known to be effective for addiction overlap with CCM approaches.

Richard Saitz, M.D., M.P.H., of Boston Medical Center, and colleagues conducted a study to examine whether CCM for alcohol and other drug dependence improves substance use outcomes compared with usual primary care. Participants (n = 563) were recruited between September 2006 to September 2008 from a freestanding residential detoxification unit, and from referrals to an urban teaching hospital and from advertisements; 95 percent completed 12-month follow-up. Participants were randomized to receive CCM (n=282) or no CCM (n=281).

The chronic care management group received longitudinal care coordinated with a primary care clinician; motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (to specialty addiction treatment mutual help). The primary care group received a timely appointment and a list of addiction treatment resources including a telephone number to arrange counseling.

The researchers found no difference in abstinence from stimulants, opioids, and heavy drinking between the CCM intervention and control group (44 percent vs. 42 percent, respectively, at 12 months). In a subgroup of patients with alcohol dependence, there were fewer alcohol problems among those who received the intervention.

The authors did not detect differences in secondary outcomes of addiction severity, health-related quality of life, or drug problems.

The authors write that current health care reforms in the United States include a focus on CCM in patient-centered medical homes to reduce chronic disease burden and to reduce costs (both of which are among the highest for those with addiction), in part because numerous studies have found such benefits for medical and mental health conditions. "Even though CCM 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," the authors write. Further research is warranted to determine whether more intensive or longer-duration CCM, or CCM designed differently, might do so."

"How should clinicians, clinical leaders, researchers, and policy makers interpret the results of this negative study?" asks Patrick G. O'Connor, M.D., M.P.H., of the Yale University School of Medicine, New Haven, Conn., in an accompanying editorial.

"… The findings may suggest that the glass is half full rather than half empty. This study places the evaluation of CCM for the treatment of substance use disorders firmly on the agenda for future research in this area. The CCM concept is sound, at least for some chronic illnesses, and highly relevant to today's evolving health care system. More research on CCM of addiction is clearly warranted to identify specific CCM approaches that may be useful for specific substance-using populations. Clinicians and health care organizations should move forward cautiously in this area pending convincing evidence that specific CCM models are effective for the treatment of substance use disorders in selected patient populations. Comprehensive, integrated management of addiction can only benefit patients—it remains to be seen how best to deliver substance abuse treatment effectively in an evidence-based manner."