Patients with an addiction may not benefit from receiving primary care treatment following the chronic care model, according to a study published in JAMA today. The surprising finding is a setback for those hoping this model, in which patients receive comprehensive care for their condition coordinated by their primary care provider, would be effective for this subgroup of patients.
A growing body of evidence suggests that the chronic care model can help improve outcomes for a range of conditions such as asthma, diabetes, and depression. This evidence had raised hopes that the approach might also be effective for individuals with alcohol or other substance abuse problems.
To test the effectiveness of the chronic care model for patients with an addiction, a team of researchers randomized 563 individuals with alcohol or drug dependence problems to receive chronic care management in a primary care setting or to receive a primary care appointment and list of treatment resources. The study found that the 2 groups did not differ significantly in self-reported abstinence, the study’s primary outcome. The researchers didn’t find any differences in severity of the patient’s condition, health-related quality of life, or drug problems between the chronic care and control groups.
Jeffrey H. Samet, MD, MA, MPH, one of the study’s authors and a professor of medicine at Boston University School of Medicine, discussed the results with news@JAMA.
news@JAMA: Why did you decide to do the study?
Dr Samet: About 10 years ago, Ed Wagner put the chronic care management model out there, and it was empirically tested and shown to be a benefit in asthma and congestive heart failure. We were interested in primary care models for addiction and we thought this might be a model. Research on depression came out showing it was something that could be handled well in primary care. It felt right.
news@JAMA: What did you think of the results?
Dr Samet: We were surprised. It really got us to scratch our heads when the outcomes showed that the difference between the groups wasn’t evident. It makes you think about things differently.
news@JAMA: Why do you think you didn’t see an effect?
Dr Samet: There is no question there are things we can do to help people with addiction. It may be a chronic disease, but we have to go back to the drawing board and think more. Some have said you only looked at treatment for 1 year; you may have to look longer. It may be a matter of the treatment taking a longer time period. We put a strong combination of interventions in place, but it is possible it wasn’t the right combination.
We need to ponder and get more people from the field to comment. We need to look at it from different angles. How are we assessing quality of care? We really facilitated people getting exposure to psychiatric care, and some of the outcomes we cared about were quality of life and utilization of health services. We have to be sure we are proving what we think we are proving. I do think it was phenomenal care and follow-up, which gives more credence to the outcome.
news@JAMA: Did you find an effect for any of the subgroups?
Dr Samet: There was 1 exception. Those with alcohol dependence had a improvement that was statistically significant. But I wouldn’t hang my hat on it. There might have been some elements of the care that worked better for the alcohol dependence group, as hinted by these results.
news@JAMA: How do your results compare with those from other studies?
Dr Samet: There was randomized study out of Kaiser by Connie Weisner in which coordinated care [that integrated] addiction and primary care had a benefit for a subgroup with alcohol problems and alcohol-related health problems. Those whose lives were being affected were more amenable to the change process. The issue people will raise is how do you motivate people who are not ready to change, to change. You don’t necessarily want to wait until they are ready because lots of damage can be done.
news@JAMA: What are the next steps?
Dr Samet: We need to go back to the drawing board and try again. There is great interest nationally; people want to service patients’ addiction needs in primary care. None of us are giving up on figuring out a better way to deliver care in that setting. It may have to be more drug specific. We’ve had good success in delivering opioid dependence treatment in primary care settings. Having a good medication is one piece of that success. There is psychotherapy for stimulant and endocannabinoid dependence and some medications for alcohol dependence. But how do we best use those? I’m up for getting a real conversation going.
news@JAMA: What do you think is the take-home message for clinicians?
Dr Samet: If you feel sometimes that treating patients with addiction is even harder than treating asthma or depression, there may be some basis for that feeling in reality. As shown in these results, a care system that worked for other chronic diseases didn’t work for these patients.
Moving forward, we need to be creative with our patients who have these problems. In terms of improving quality of care, we need both randomized control trials and observational studies. I wouldn’t steer the ship away from primary care treatment; the reality is that most patients with depression and addiction get their care in primary care. Do we need specialist help? Yes, but we need a primary care system that will do its bit as well.