Novel Addiction Program May Boost Recovery Odds

Pam Harrison

June 27, 2016

Patients who are taught how to access health information resources via a novel addiction treatment program are more likely to talk to their primary care provider about their addiction problems, and this increased communication appears to prevent relapse, new research shows.

"Addiction treatment programs have traditionally been quite isolated from medical care, but having a meaningful relationship with their primary care provider and being actively engaged with their healthcare, including preventive services, could have a beneficial impact on recovery over time,"

Constance Weisner, DrPH, professor of psychiatry, University of California, San Francisco, told Medscape Medical News in an email. Dr Weisner is also affiliated with the Kaiser Permanente Northern California, in Oakland.

"We anticipate that these experiences can build upon each other to reinforce recovery, and a meaningful relationship with their primary care provider will help patients to identify signs of potential relapse."

The study was published online June 22 in JAMA Psychiatry.

More Communication

For the study, 252 patients with alcohol and other drug use (AOD) disorders were assigned to the LINKAGE intervention, and another 251 patients with AOD were assigned to usual care.

The LINKAGE intervention consists of six 45-minute sessions. Each session focuses on a different aspect of health and prevention. The program also teaches patients to use a secure Internet portal for email, for viewing laboratory test results, for access to prevention services.

In addition, patients are taught how to better communicate with their primary care physician and how to reduce relapse risk and optimize their own health.

Participants assigned to the usual-care group received six regular medical education sessions commonly used in public and private programs for patients with substance use disorders.

"Participants in both arms received standard treatment, including medical examinations and detoxification," said Dr Weisner.

For the first 2 weeks of the study, patients' conditions were stabilized, and the patients were then assigned to either the LINKAGE program or usual care.

Group therapy, individual counseling, 12-step meetings, and weekly breathalyzer and urine screens were all part of the standard treatment program.

Among those assigned to the LINKAGE intervention, almost all patients attended at least one session. More than 55% attended one to five sessions, and more than 42% attended all six sessions. Similar percentages seen for patients receiving usual care.

Telephone interviews were conducted 6 months after patients had been enrolled in the trial. More than 90% of patients participated in these interviews.

"LINKAGE participants had twice the odds of having talked with their primary care physician about AOD problems (odds ratio, 2.30; P < .001)," the researchers report.

This was true for the full sample as well as a subgroup of patients with psychiatric comorbidities. In this latter group, assignment to the LINKAGE intervention increased by 60% the likelihood of their talking with their primary care physician about AOD problems (OR, 1.60; P = .05) in comparison with the patients receiving usual care.

"At 6 months, participants in both conditions had higher mean Patient Activation Measure [PAM] scores than at baseline," Dr Weisner said. The PAM consists of 13 items that measure change in patient activation.

Dr Weisner suggested that improvement in scores on the PAM scale likely reflected an improvement in participants' substance use problems.

LINKAGE patients also used an Internet patient portal significantly more during the 6-month intervention; the difference between the two groups remained significant through the 6-month follow- up period.

Those assigned to the LINKAGE intervention had a 53% increase in the mean number of portal log-in days compared with those assigned to usual care (P = .001). Similar results were observed for the various types of patient-portal activities that patients could engage in, as follows:

  • Participants in the LINKAGE intervention were 55% more likely to use the patient portal for medical advice than were patients receiving usual care (P = .006).

  • The mean number of messages sent by a healthcare professional was 45% greater for the LINKAGE participants than for those receiving usual care (P = .02).

  • The mean number of log-in days to review laboratory test results was 92% greater for the LINKAGE participants than for patients receiving usual care (P < .001).

  • The mean number of log-in days to obtain laboratory test information was 89% greater for LINKAGE patients than for usual-care patients (P < .001).

Among the subgroup of patients with psychiatric comorbidities, those assigned to the LINKAGE intervention utilized to a significantly higher degree each activity accessible through the Internet portal.

High Abstinence Rate

Rates of abstinence at 6 months were high, at 70% or greater, in both groups, and symptoms of depression also improved in both groups. At baseline, 15% of the cohort had a score of 15 or greater on the Patient Health Questionnaire; this had dropped by about half, to 8%, at 6 months.

Importantly, patient portal use was higher among LINKAGE participants who received all six sessions compared with those who received fewer sessions. Among the high-uptake group, total abstinence rates were higher for those who had more LINKAGE sessions than for those who had fewer (~77% vs ~65%, respectively).

Participants who received the most LINKAGE sessions also stayed in treatment longer, at 103.8 days, in comparision with those who had fewer LINKAGE sessions, at 60.4 days (p < .001).

Dr Weisner emphasized the fact that the LINKAGE intervention did not focus on alcohol use, other drug use, or depression, because that was the focus of the standard treatment program, which is a very intensive, evidence-based program.

"By taking better care of their health, we expect that LINKAGE participants will have better outcomes than usual-care participants over time," Dr Weisner noted.

"Because AOD disorders are chronic health conditions requiring ongoing care, we also expect that by engaging patients in their healthcare, potential service needs will be identified earlier and relapse avoided," he added.

Selection Bias?

Commenting on the findings for Medscape Medical News, James McKay, PhD, professor of psychology in psychiatry, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, found the nature of the LINKAGE intervention itself a bit hard to grasp. To him it seemed that the LINKAGE program was not so much a technology-driven intervention but rather a more traditional, classroom-based intervention in which patients are taught to use the electronic portal to gain access to their primary care physician and to test results.

"My take on the findings is the intervention was indeed successful in getting patients to talk to their primary care physician about their addiction problems, and it was much more effective than treatment as usual," Dr McKay said.

"However, there doesn't seem to be any evidence that the intervention actually improved substance use outcomes," he noted.

The fact that participants who attended all six sessions seemed to do better in terms of higher abstinence rates and of staying in treatment longer in comparision with those who attended fewer sessions is a reflection of self-selection bias, he added, inasmuch as the patients who attended more frequently were likely to be more motivated than the others and were thus more likely to have slightly better outcomes.

"I think this is very promising idea, and there is reason to believe that it is to a patient's benefit to be able to talk to their primary care provider about their substance use issues," said Dr McKay.

"What is still to be determined is whether the intervention leads to better substance use outcomes or not, and there is a need to follow people longer to see if this approach actually produces better outcomes, as 6 months may just not be long enough."

The authors and Dr McKay have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online June 22, 2016. Full text

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