Regular primary care and specialty care as needed is associated with remission from alcohol and drug use disorders over 9 years
What effect does a continuing care model and its components have on remission status in people with substance use disorders?
991 people with substance use disorders (alcohol or drugs or both). These individuals were selected from 1953 people who were taking part in two large randomised studies assessing day hospital treatment and integrated care. Participants had to have been Kaiser Permanente members for at least 5.4 years in the study period, and have had at least one follow-up interview.
Kaiser Permanente Sacramento Chemical Dependency Recovery Program, USA; from 1994 to 2007.
Type of service use (including primary care, specialty substance abuse treatments and psychiatric services, as well as continuing care). The initial model included demographic characteristics, baseline alcohol and drug dependence, completion of index treatment, severity of substance use and psychiatric problems (Addiction Severity Index, ASI), at previous follow-up. Subsequent models included those factors that were significant at the p<0.1 level in the initial model. Receiving continuing care was defined based on the components of care found to be associated with increased chance of remission (attending ≥1 primary care visit per year; completing initial substance abuse treatment or being readmitted in year 1; receiving substance abuse treatment if needed (alcohol and drug ASI scores of zero at the previous interview, or being readmitted if score >0); and receiving psychiatric treatment if needed (psychiatric ASI score of zero at the previous interview or being readmitted if score >0).
Remission, defined as abstinence or non-problematic substance use in the past 30 days. Non-problematic use was defined as drinking ≤4 times in the previous month; not having ≥5 drinks on any given day; not using marijuana more than once; not using any drug other than alcohol or marijuana; and not having suicidal ideation, violent behaviour or serious conflict with friends, family or colleagues.
At 1 year of follow-up, 71% of the participants were in remission, and at 5, 7 and 9 years, 65% were in remission, respectively. Overall, 15% or fewer of the participants met the definition of receiving continuing care at 1, 5, 7 and 9 years. Those who received continuing care were more likely to achieve remission at follow-up than those who did not receive continuing care (OR 2.34, 95% CI 1.57 to 3.47).
Receiving annual primary care visits and specialty care as needed (in the form of substance abuse treatment and psychiatric services) was associated with achieving remission over a 9-year period in people with alcohol and drug use disorders.
The study by Chi et al represents a significant advancement in the field of addiction health services research. Importantly, the study found that individuals who display symptoms of substance use or psychiatric problems, and who receive continuing care for these problems over a 9-year period, have a higher probability of long-term remission.
The study carefully examines the sequenced effects of need for treatment and subsequent treatment received and provides further evidence that a chronic care model, in which ongoing monitoring and assistance is provided following initial treatment, is superior to an acute care model of addiction treatment.1 Moreover, the study advances our understanding of the specific components of continuing care by demonstrating that receipt of regular primary care services, and of minimum thresholds of substance abuse and mental health services for those who need these services, approximately doubles the probability of sustained remission. Given the high rates of comorbid health and psychiatric problems among individuals with substance use disorders,2 moving addiction treatment into the healthcare mainstream is a big step to improving the overall health of these individuals.
Participants in this study were enrolled in a large, managed care health plan; thus, they had higher levels of employment, education and income than is typical of patients who are in publicly funded substance abuse treatment and/or who lack a regular healthcare provider. Replication of the study's findings with other samples, particularly those with higher levels of problem severity, is needed to determine optimal levels and combination of services among patients in different treatment settings. Moreover, the challenges of implementing continuing care with patients who enter treatment at lower levels of psychosocial functioning will need to be addressed. The present study provides a good platform for moving forward in answering these questions, which will shape the delivery of addiction treatment services in the years to come.