The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients

Division of Research, Kaiser Permanente Medical Care Program, 2000 Broadway, 3rd Floor, Oakland, CA 94612, United States.
Drug and Alcohol Dependence (Impact Factor: 3.42). 07/2008; 98(1-2):45-53. DOI: 10.1016/j.drugalcdep.2008.04.007
Source: PubMed


Health problems are prevalent in chemical dependency (CD) treatment populations, and often precede reductions in substance use among untreated populations. Few studies have examined whether medical problems predict better long-term outcomes in treated individuals, or how primary care utilization and CD/primary care service integration affects long-term outcomes among those with health problems.
In a sample of 598 CD patients in a private health plan, logistic regression models examined whether substance abuse-related medical conditions (SAMCs), integrated medical and CD care, and on-going primary care predicted remission of CD problems at 5 years.
Those with SAMCs were no more likely than others to be remitted at 5 years except among young adults and those with medical, but not psychiatric SAMCs. Higher levels of medical problem severity at intake and receiving integrated CD and primary care in the index treatment episode predicted remission in the full sample and among those with SAMCs. Among those with SAMCs, individuals with ongoing medical care - 2-10 primary care visits - in the 5 years following intake were more likely to be remitted at 5 years than those with fewer visits.
This study highlights the potentially important role of medical services in the long-term treatment of CD disorders. CD treatment may benefit from a disease management approach similar to that recommended for other chronic medical problems: specialty care when the condition is severe followed by services in primary care when the condition is stabilized.

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    • "Integrated models have been shown to be cost-effective for individuals who have substance use related medical conditions (Weisner, Mertens, Parthasarathy, Moore, & Lu, 2001). Mertens et al. (2008) studied a sample of private health care plan enrollees with substance use related medical conditions and demonstrated that having between two to ten primary care visits was predictive of remission of substance dependence after five years of followup . Samet et al. (2001) have reviewed the benefits of integrating primary care and substance user services and describe various models that can be implemented within today's health care delivery system. "
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    ABSTRACT: The Western approach to addiction treatment involves a medical or disease orientation to understanding the onset, course, and management of addiction, and a clinical goal of abstinence or very significant reductions in drug use, usually with a combination of behavioral and pharmacological interventions. Even within this Western approach, and despite several consensually accepted features of addiction, a significant mismatch remains between what this culture has come to accept as the nature of the disease and how that same culture continues to treat the disease. This paper discusses the evolution of these Western concepts over the past decade without a corresponding evolution in the nature, duration, or evaluation standards for addiction treatment. (1) Here, we take the position that continuing care and adaptive treatment protocols, combining behavioral therapies, family and social supports, and, where needed, medications show much promise to address the typically chronic, relapsing, and heterogeneous nature of most cases of serious addiction. By extension, methods to evaluate effectiveness of addiction treatment should focus upon the functional status of patients during the course of their treatment instead of post-treatment, as is the evaluation practice used with most other chronic illnesses.
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    • "The primary AOD outcome was prior-year remission , measured at 5, 7, and 9 years. Remitted individuals were those who either reported abstaining in the past year or those who were non–problem users as follows: They (a) used alcohol but had no days of drinking fi ve or more drinks in a day and drank only four times per month or less in the past year, or used marijuana but not more than once per month in the past year; (b) had no other drug use in the past year; (c) had no problems with friends or family, violent behavior, or suicidal ideations in the month before the interview; and (d) had not been arrested, in jail/prison, under electronic home surveillance, or to a probation or parole offi cer in the year before the interview (Mertens et al., 2008). This is consistent with other " remission " defi nitions (Moos and Moos, 2003). "
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    ABSTRACT: The purpose of this study was to examine the effects of age, common life transitions, treatment, and social support on outcomes 5-9 years after alcohol and other drug (AOD) treatment intake. Participants were patients from a large outpatient AOD treatment program in an integrated health plan. There were 1,951 participants interviewed at intake, of whom 1,646 (84%) completed one or more telephone follow-up interviews at 5, 7, and 9 years. Measures included AOD use based on the Addiction Severity Index; treatment; and changes in marital, employment, and health status in the years between each follow-up. We compared participants by age group (18-39, 40-54, and ≥55 years old at intake) and examined factors (time invariant and time varying) associated with outcomes at 5, 7, and 9 years by fitting mixed-effects logistic random intercept models. Changes in marital, employment, and health status varied significantly by age. Factors associated with remission across Years 5-9 included being in the middle-aged versus younger group (p < .001); female gender (p < .001); not losing a partner to separation, divorce, or death (p < .001); not experiencing a decline in health (p = .021); having any close friends supportive of recovery (p < .001); and not having any close friends who encourage AOD use (p < .001). Additional predictors, including employment changes, varied by drug versus alcohol abstinence outcome measures. Negative life transitions vary by age and are associated with worse outcomes. Older age and social support are associated with long-term AOD remission and abstinence. Findings inform treatment strategies to enhance recovery across the life span.
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    • "utilization in the second and third years not paid for by KP following intake was measured using self-report data from the 3-year interview. Analyses conducted in another KP sample of young adults aged 18 to 25 years old found substantial agreement between self-report and administrative data (Mertens et al., 2008). "
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    ABSTRACT: Few studies have examined the effects of treatment factors, including the types of services [chemical dependency (CD), psychiatric, or both], on long-term outcomes among adolescents following CD treatment, and whether receiving continuing care may contribute to better outcomes. This study examines the effect of the index CD and ongoing CD and psychiatric treatment episodes, 12-step participation, and individual characteristics such as CD and mental health (MH) severity and gender, age, and ethnicity, on 3-year CD and MH outcomes. Participants were 296 adolescents aged 13 to 18 seeking treatment at 4 CD programs of a nonprofit, managed care, integrated health system. We surveyed participants at intake, 1 year, and 3 years, and examined survey and administrative data, and CD and psychiatric utilization. At 3 years, 29.7% of the sample reported total abstinence from both alcohol and drugs (excluding tobacco). Compared with girls, boys had only half the odds of being abstinent (OR = 0.46, p = 0.0204). Gender also predicted Externalizing severity at 3 years (coefficients 18.42 vs. 14.77, p < 0.01). CD treatment readmission in the second and third follow-up years was related to abstinence at 3 years (OR = 0.24, p = 0.0066 and OR = 3.33, p = 0.0207, respectively). Abstinence at 1 year predicted abstinence at 3 years (OR = 4.11, p < 0.0001). Those who were abstinent at 1 year also had better MH outcomes (both lower Internalizing and Externalizing scores) than those who were not (11.75 vs. 15.55, p = 0.0012 and 15.13 vs. 18.06, p = 0.0179, respectively). A CD treatment episode resulting in good 1-year CD outcomes may contribute significantly to both CD and MH outcomes 3 years later. The findings also point to the value of providing a continuing care model of treatment for adolescents.
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