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Integration demands highest standard of care

March 5, 2014
by Shannon Brys, Associate Editor
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Tom McLellan

Addiction treatment outcomes don’t get taken seriously – not by the public, not by other medical professions, and certainly not by insurers. Tom McLellan, chief executive officer of the Treatment Research Institute (TRI), said as far as substance abuse is concerned, “we got it wrong for about 40 years.”

Addiction is typically looked at as “a criminal justice issue” and “a bad habit” while substance use is considered the product of poor morality, bad parenting, poor self-control, etc., explained McLellan, who spoke at the Rosalynn Carter Symposium on Mental Health Policy.

He explained that the treatment process in the addiction field is much like a washing machine in that the substance abuser gets placed into treatment for 30 days or 12 sessions and then after that, there is an expectation that the patient will have learned his lesson, that he will “get it.” At this point, there is a graduation ceremony.

McLellan, whose daily work is comprised of gathering research about treatment outcomes, said that six or 12 months post-treatment, patients are polled to find out if they are still sober. Sometimes they are, but the majority of the time, they are not. The relapse rates, he said, are very similar to those of hypertension, diabetes and asthma. There is a 50% relapse rate within 6 months of leaving treatment.

The average duration of treatment in a substance abuse program is one day for outpatient treatment, and five days for a residential facility. These results, perhaps not surprisingly, have left the public skeptical of addiction treatment.

“Evaluation has always occurred as you might evaluate the results of a cast for a broken leg,” he said. “It’s always occurred following the completion of care – six months or a year later.” Another thing about evaluation for the field is that it has never been a clinical activity as it is not reimbursed or considered.

Differences among chronic illnesses

With other chronic illnesses, symptoms are detected by primary care because nurses, doctors, and clinical teams have been educated and trained to identify them, they are reimbursed to do it, and because they have the tools, medications and interventions (which are all also reimbursed) to address these issues. “The incentives are all there,” McLellan explained.

Many times in primary care these issues, such as hypertension, will be addressed and the problem will be arrested. Often the care doesn’t work and that’s when the patient will get referred to specialty care. In these instances also, specialty care is intended to educate the patient and family, reduce the acuity of symptoms, and then send the patient back to the primary care doctor. “There are no 30-day diabetes programs, and they certainly don’t have graduation ceremonies,” said McLellan. “That would be malpractice.”

Patients with a chronic illness return to the primary care doctor after specialty care because the goal isn’t to be “cured, but rather to have good management.”

Research speaks

A common assumption among clinicians in the field is that there are different types of treatment that work better for different types of patients. However, that’s not always the case, said McLellan. He noted two studies that were very similar in method but very different in concept.

The first was one of the largest studies ever completed by the National Institute of Alcoholism and Alcohol Abuse (NIAAA), called Project MATCH. The study evaluated three different treatments -- motivational enhancement therapy (short-term because it had 4 sessions), cognitive behavioral therapy (long-term with 12 sessions), and 12-Step oriented treatment (also long-term with 12 sessions). Though patients were randomly assigned to each of the three treatment modalities, the researchers had prespecified that certain types of patients would do best with certain types of programs.

McLellan attests that some of the “best groups in the substance abuse field” worked together on this and had a common goal of lasting abstinence. After the $27 million research project was complete, researchers didn’t find what they had suspected – there were no significant outcome differences based on their predictions.

All individuals were abstinent at the beginning of the study because they were recruited right out of residential care. The results were as follows:

  • By 6 months post-treatment, 45% were still abstinent and there were no significant differences among the three treatment modalities
  • By 18 months, the number had dropped to 38%, and,
  • By 36 months, only 27% of patients were still abstinent.

“This was a big black eye for NIAAA,” stated McLellan. He said that many of the researchers even called it “a waste of government funds.”

At the same time that this study was being conducted, another -- Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack (ALLHAT) -- conducted by the National institutes of Health (NIH) was seeking to answer a similar question. The study considered three treatment options -- diuretics, calcium channel blockers, and ace inhibitors – for controlling blood pressure following primary care treatment.

Just 27% of the patients had met criteria for blood pressure control at the time that they were assigned to one of the three groups. Much like the MATCH study, ALLHAT researchers believed that certain patients would do better with certain medication/treatment types, but found they were wrong.  The difference? “Nobody got all upset about [the results] because they went from 27% of patients who during the course of treatment had reached blood pressure control to 42%,” explained McLellan.