November 08, 2017

New Program Closes Gap in Addiction Treatment

A new program at Boston Medical Center's Grayken Center for Addiction is showing that connecting patients to addiction treatment when they are hospitalized for other conditions can be a powerful tool in closing a gap in addiction treatment. In fact, early results show that many of these patients continue treatment after they are discharged, underscoring the importance of reaching patients who might otherwise not get treatment for their addiction.

Approximately 17 percent of patients admitted at BMC have an active substance use disorder. This led providers to look for new ways to engage patients in addiction treatment when they were already here.

To accomplish this, they developed and implemented an inpatient addiction consult service, which is staffed by a multidisciplinary care team with expertise in treating addiction.

Ready for Treatment

"In order to help curb the epidemic, we need to take every opportunity to engage patients with substance use disorders and get them into treatment when they are ready," said study lead author Paul Trowbridge, MD, and graduate of BMC's addiction medicine fellowship. "This service will not only prove beneficial to patients, by helping them get access to evidenced-based treatment, but also to the health care system by reducing costs and readmissions."

Researchers found the initial results promising: Methadone treatment was initiated for 70 patients and 76 percent were linked to a methadone clinic upon discharge. Upon follow up, 54 percent were still receiving methadone at 30 days, 39 percent at 90 days, and 29 percent at 180 days.

Buprenorphine was initiated in 40 patients as a result of the consult, and 49 percent were linked to an outpatient clinic at discharge. Upon follow up, 39 percent were still engaged in treatment at 30 days, 27 percent at 90 days and 18 percent at 180 days.

Treating the Root Cause

"Like heart disease can cause a heart attack or a stroke, addiction causes many acute injuries requiring immediate attention, but we can't simply treat that issue without delving deeper to address the root cause," said Alex Walley, MD, MSc, a general internist at BMC's Grayken Center for Addiction who also oversees the addiction medicine fellowship. "Our goal is to engage willing patients in treatment and work with them on a plan that will keep them healthy and safe now and in the future."

The authors note that treatment is not one size fits all and that there is a need for additional treatment programs and services that meet the needs of even more patients both in the short and long term.

This study was published in the Journal of Substance Abuse Treatment.

Posted by Webmaster at 03:56 PM

September 06, 2017

Opioid Abuse Can Be Treated in Primary Care

A new model of collaborative care - combining substance abuse treatment with regular medical care - has been found to be more accessible, more effective and at a lower cost that traditional speciality care methods, according to a new RAND Corporation study.

Patients who enrolled in a program that combined substance abuse treatment with primary medical care were more than twice as likely to receive treatment for opioid or alcohol abuse, as compared to peers who received usual primary care services, according to the study.

The patients in the collaborative care model also were significantly more likely to report abstinence from opioids or alcohol six month after beginning care, a key marker to successful recovery. The findings are published online by the journal JAMA Internal Medicine.

Increasing Access to Treatment

"This new model of integrating treatment for substance use disorders with a patient's primary medical care could expand access to drug treatment at a lower cost and in a more accessible fashion," said Dr. Katherine E. Watkins, the study's lead author and a senior physician scientist at RAND, a nonprofit research organization. "This is a way to increase access to evidence-based substance use treatment, without having to convince patients to go to a specialized drug treatment center."

Deaths in the United States are rising from increases in drug overdoses and alcohol-related liver disease, yet many substance use disorders continue to be under identified and undertreated.

While treatment in specialty care settings is important for people who have severe dependence, researchers say that access to such care is limited and the stigma associated with drug treatment means that specialty care alone is insufficient to address the nation's treatment needs.

Collaborative Care System

The RAND study involved 377 people with opioid or alcohol abuse disorders who received medical care at two locations operated by a safety-net medical provider in the Los Angeles area. The clinics were part of a federally qualified health center.

Participants were randomly assigned to receive their medical care from either the clinics' usual primary care providers or from providers who were partnered with therapists and care coordinators who received special training to provide evidence-based substance use treatment.

The collaborative care system was designed to increase delivery of a six-session brief psychotherapy treatment and/or medication-assisted treatment to reduce cravings for opioids or alcohol. Patients receiving usual care were told the clinic provided substance use treatment and were given a phone number to schedule an appointment, as well as a list of community referrals.

Works Better Than Specialty Care

Most of the patients in the study had challenges that were viewed as an obstacle to receiving successful treatment, with nearly half of the group being homeless at the time of enrollment.

Among those treated in the collaborative care model, 39 percent received some type of substance abuse treatment, compared to 16.8 percent among those treated in the usual primary care system.

After six months, 32.8 of the participants in the collaborative care model reported that they had abstained from opioids or alcohol in the previous month, compared to 22.3 percent treated in the usual primary care system. Researchers say that among people with substance abuse problems, abstinence is linked to a lower likelihood of relapse compared with nonproblem use.

"Our findings suggest that it is possible to successfully treat people who are addicted to opioids or alcohol in a primary care setting," Watkins said. "The collaborative care model can be a lower-cost and more-accessible way to treat opioid addiction than expanding the nation's supply of specialty care clinics."

Posted by Webmaster at 07:45 PM

August 14, 2017

12 Steps Improve Youth Treatment Outcomes

A treatment program for adolescents with substance-use disorder that incorporates the practices and philosophy of 12-step programs like Alcoholics Anonymous (AA) produced even better results than the current state-of-the art treatment approach in a nine-month, randomized trial.

The results of the study, led by a Massachusetts General Hospital (MGH) psychologist, are published online in the journal Addiction.

"While all adolescents can improve when they receive well-articulated substance-use disorder treatment, we showed that adding a 12-step component to standard cognitive-behavioral and motivational strategies produced significantly greater reductions in substance-related consequences during and in the months following treatment," says John Kelly, PhD, director of the Recovery Research Institute in the MGH Department of Psychiatry, who led the study. "It also produced higher rates of 12-step meeting participation, which was associated with longer periods of continuous abstinence."

Combining Treatment Approaches

While it is common for adolescent treatment programs in the U.S. to link patients to mutual-help organizations like AA, Narcotics Anonymous (NA) or Marijuana Anonymous (MA), the effectiveness of combining 12-step approaches with motivational enhancement/cognitive-behavioral therapies has not been clear because there has been no well-defined treatment protocol integrating both approaches for young patients.

The intervention developed by the team was based on motivational/cognitive-behavioral approaches but also included information about and the kinds of discussions featured in 12-step program meetings.

Conducted at the MGH Center for Addiction Medicine, the study enrolled 59 participants, ages 14 to 21, who met substance-use disorder criteria and had been actively using within the past 90 days. Participants were randomly assigned to either a standard motivational enhancement/cognitive behavioral program or the Integrated Twelve-Step Facilitation (iTSF) program.

Reducing Relapse Risk

Both programs featured 10 consecutive weekly sessions -- two individual sessions with a therapist and eight group sessions. The motivational enhancement/cognitive-behavioral approach was designed to enhance adolescents' motivation for change towards remission and recovery. Sessions focused on teaching and practicing cognitive-behavioral relapse prevention and coping skills and included setting and reporting on weekly treatment goals.

Group sessions for the iTSF group included discussions of topics such as changing social networks and reducing relapse risk. Two of the sessions featured young members of NA or MA who shared their own experiences with addiction and recovery.

"That peer-to-peer aspect was probably the most powerful in disabusing young people of the negative stereotypes they often hold about 12-step members and about recovery more broadly," says Kelly. "Similar-aged peers who are in recovery seemed much better able to capture the attention of participants than clinic staff."

Fewer Substance-Related Consequences

Along with the weekly reports at their sessions, participants were formally assessed upon entering the study and then three, six and nine months later. At the end of the study period, both groups showed similar improvements in the primary outcome, percent days abstinent. But those in the iTSF group had greater attendance at 12-step meetings during the three months that included the intervention.

Participants in the iTSF group also reported significantly fewer substance-related consequences - things like feeling unhappy, guilty or ashamed because of their substance use; neglecting responsibilities; taking risks; having money problems; damaging relationships with family and friends, and having under-the-influence accidents.

The fact that the greater rate of 12-step attendance among the iTSF group was not maintained after the intervention program may indicate the need for a longer treatment program or regular, follow-up visits.

Longer Term Care Needed

"We want to replicate and extend the testing of this treatment even further to determine the benefits of longer term care," Kelly explains. "We know that the transition to adulthood is fraught with relapse risks for young people recovering from a substance-use disorder, so some kind of regular but brief 'clinical recovery check-up,' like what is common for other chronic conditions like diabetes or hypertension, could improve outcomes."

Kelly, who is the Elizabeth R. Spallin Associate Professor of Psychiatry in the Field of Addiction Medicine at Harvard Medical School, adds, "In countries like the U.S., the greatest health risks for young people by far are from alcohol or other drug use. Cognitive-behavioral and motivational programs are evidence-based, popular approaches for addressing youth substance-use disorder, and now these data suggest that integrating these approaches with 12-step philosophy and practices can further help reduce the impact of substance use in their lives and potentially facilitate higher rates of abstinence.

"Given the prevalence of substance-use disorders among young people, having treatments that are both effective and cost-effective -- linking patients to free and ubiquitous community resources -- is needed and welcome."

Posted by Webmaster at 03:40 AM

Trusting Counselor Vital to Treatment Success

A positive, trusting relationship between counselor and patient, known as a "therapeutic alliance," can be key to successful treatment of alcohol use disorder, a study finds. Gerard Connors, PhD, senior research scientist at the University at Buffalo Research Institute on Addictions, studied more than five dozen people engaging in a 12-week program of cognitive behavior therapy for alcohol use disorder.

Patients who reported the most positive relationships with their counselors on a session-to-session basis had fewer days of drinking and fewer days of heavy drinking between treatment sessions than patients whose relationship was not as positive.

Positive Relationship Yields Better Results

The results indicate that efforts to ensure a good match between patient and counselor can have considerable benefits to the patient's recovery, Connors says. Further research on what factors lead to strong therapeutic alliances in alcohol treatment could be warranted.

Historically, there was an expectation that the most effective process to treat alcohol use disorder involved therapists confronting their clients about their behavior. However, Connors' work over several years, along with other emerging research, has shown a more positive relationship between therapist and client yields better results.

"Many recent studies have recognized that a positive therapeutic alliance between a therapist and client is necessary for achieving behavior change, but much less has been known about how alliances operate across a full course of treatment," Connors says.

Risk of Dropping Out of Treatment

"By studying the alliance on a session-to-session basis, we could see how a fractured alliance at a given point in time interferes with the pursuit of treatment goals by running the risk of a client dropping out of treatment," he says. "Therefore, it's important for the therapist to continue assessing the alliance throughout the entire course of treatment."

The study also showed a positive alliance was even more critical for patients who had not made changes in their drinking prior to starting treatment. "In contrast, patients who had already reduced their drinking prior to entering treatment were not as dependent on the therapeutic alliance to continue the process of behavior change," Connors says.

Posted by Webmaster at 03:15 AM