Study: 2 Programs Equal for Substance Abuse

September 18, 2013

News Review From Harvard Medical School -- Study: 2 Programs Equal for Substance Abuse

A program of long-term support may not help people with addictions any more than a brief visit and treatment referral, a study suggests. The study included nearly 600 adults who abused alcohol or drugs. They were randomly divided into 2 groups. One group was assigned to a program of chronic care management. It included medical care at a primary care clinic. People also received addiction and psychiatric treatment. They got counseling to help keep up their motivation and prevent relapse. People in the other group saw a primary care doctor and received a list of addiction treatment resources. They also could get 4 sessions aimed at strengthening their motivation to quit, and follow-up care. After a year, 44% of those in the chronic care group had quit drinking or using drugs. About 42% of those in the other group also had quit. One expert told HealthDay News that quitting substance abuse mostly depends on motivation. This may be why the programs had similar results.  Researchers said chronic care management may still be better for some people or some addictions. The Journal of the American Medical Association published the study. HealthDay wrote about it September 17.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

The number of people worldwide who overuse alcohol and illicit drugs is staggering. And so are the consequences.

Surveys on alcohol use indicate that 25% of teens and adults report binge drinking at least once in the last month. And 6% of them report bingeing 5 or more times within that same time period. Binge drinking is defined as having 5 or more drinks on one occasion for a man or 4 for a woman.

Surveys on illicit drug use show that 22 million teens and adults used illicit drugs in the last 30 days.

It's widely assumed that the best approach to alcohol and drug abuse is a long-term approach. It's known as disease management or chronic care management.

The model is similar to programs used to treat people with diabetes, heart failure and chronic lung disease. A team of health care professionals closely monitors and advises patients to help control their long-term condition. In theory, the close supervision will help people to take medicines properly and follow restrictions on diet. This should mean fewer visits to the hospital and ultimately cost savings. But the actual cost savings for disease management have been less than predicted.

There is widespread belief that the same type of chronic care management improves outcomes for people with substance abuse. In my experience, substance abuse consultants have always recommended such an approach. So you would think that there was good evidence to support this practice. In fact, it hasn't been rigorously studied until now.

In this well done study, people were randomly assigned to one of two programs:

• Chronic care management, including:
  • Long-term primary care
  • Continuing motivational therapy
  • Relapse prevention counseling
  • Social work assistance
  • Other specialized care and counseling as needed
• A single primary care visit plus brief therapy -- People received a list of addiction treatment resources. They also got access to four sessions to reinforce their motivation to quit. Patients needed to arrange the visits. They also could request follow-up primary care visits.

The researchers were surprised -- I actually think they were shocked -- to find no difference in the results after 12 months. Both groups had similar rates of:

• Substance abuse relapse
• Emergency room visits
• Hospital stays

They also had similar quality of life measurements.

Naturally, the up-front cost of chronic care management was much greater than the other, very limited program. And this meant greater overall costs for chronic care management because all other costs were similar for both groups.

What Changes Can I Make Now?

Chronic care management may not be the best care model for all patients with substance abuse problems. But some important positives did come out of this study.

An extended visit with a primary care doctor to address substance abuse is clearly worthwhile. The number of patients in both programs who abstained from abuse for 12 months was greater than usually seen in other studies. More than 40% were not using after a year.

So, the important message here is: Get help if you are drinking more than you should or using illicit drugs. Start with your primary care doctor. Friends and family of the person at risk can arrange the appointment. Let the office know exactly what is needed. This type of visit requires more time than the usual check-up.

Almost everyone who drinks too much or uses illicit drugs is aware of the harm it can cause. Why do so many keep doing it? One reason: They don't accept that the harm applies to them.

The Health Belief Model helps us understand why so many people continue with bad health habits. Often they do this even knowing that the risks of getting sick or dying are very high.

Reading and hearing the reasons for stopping substance abuse is not enough. To change behavior, you must absolutely believe that you are the one who will lose your job, or destroy your family and friendships, or become penniless and homeless. Believing in these consequences is often more powerful than the belief of how very sick you will get.

Once you believe bad things will happen to you if you continue your current behavior, you are much more likely to seek the professional guidance and tools to help you succeed. 

What Can I Expect Looking to the Future?

Substance abuse specialists will examine the details of their current programs. Using information from this study, they can redesign their models to make better use of current financial resources to improve quit rates and other outcomes.