Study will test unusual but creative format to empower outpatients

A research project involving Philadelphia's largest provider of intensive outpatient services for addiction and the Treatment Research Institute (TRI) has an ambitious goal for participating outpatients: not only to keep them engaged in services, but to empower them with treatment options and encourage them to advocate for themselves.

The three-year research contract valued at more than $2 million will use an innovative tool to deliver its message: a multi-volume graphic novel series in which the main characters will be struggling with dilemmas related to their substance use and how they can get help.

“We're envisioning a four-volume series that can be used in the beginning of treatment, to orient the patient to outpatient treatment,” says Adam Brooks, PhD, TRI's senior scientist. “We will tell the story with three or four main characters, all of whom are starting treatment. All of them are struggling with whether they need to take medication as part of their recovery.”

What is also noteworthy about this newly launched project involves where the money is coming from. The Patient-Centered Outcomes Research Institute (PCORI) approved the proposal last summer as one of 33 projects to advance the field of patient-centered comparative effectiveness research. Brooks says relatively few PCORI-funded initiatives to empower patients have concentrated on addiction or mental health.

“So much of what we see in the cycle of treatment and recidivism is a sense of hopelessness,” says Lawrence M. Schoen, PhD, director of research and analytics at participating provider agency Wedge Medical Center in Philadelphia. “We want to communicate to patients, 'You're not just a recipient of services.'”

Experience with format

This is not the Philadelphia-based TRI's first experience with testing the merits of a patient tool using fictional characters. The idea originally grew out of concern that busy counselors often don't have time to review the evidence-based clinical tools they are asked to share with their patients. Researchers often will hear, “I never watched the video before I showed it to my client,” says Brooks.

For an earlier TRI study population of moderately using patients whose problems were detected in primary care settings, the idea of creating a self-help book evolved into a comic book, depicting characters who were able to make changes in their lives on their own. Over the course of this prior TRI project, which focuses on individuals who do not require primary addiction treatment, it was suggested that it would be ideal to create a similar tool for individuals with more serious alcohol or drug problems.

A team of clinicians and patients is currently helping to design the themes and characters for the novel series that will be used in the latest project, which officially began in October. Each volume in the series likely will consist of 40 to 50 pages, featuring comic art and interspersed with psychoeducation and self-help exercises. An example from the earlier study depicts a scenario in which a character is deciding whether to buy beer, and proceeds to compile a list of the pros and cons of that decision.

In the new series, medication-related decision-making will be the focus. One character will be opioid-dependent and will be confronting a number of medication options, Brooks says. Another will be alcohol-dependent and might be torn over whether to use medications at all. The series will seek to deliver the message that consumers have options, and that in some cases they might have to speak up and ask for what they need—particularly given the access barriers to medication-assisted treatment in service systems, Brooks says.

Adds Schoen, “The idea is to give patients more choice, more control, more say in their own treatment. This approach is a '180' from the outset, where many patients are court-stipulated, which is the opposite of having choice.”

Measuring success

In the earlier study of this clinical toolkit format with the moderate-use population, TRI has been able to show that with minimal training of clinicians, exposure to the curriculum resulted in reduced use of alcohol and drugs, Brooks says. In the new study, researchers again will compare groups of patients exposed and not exposed to the novel series. They will look primarily at whether patients reduce use after they are introduced to the concepts in the series, and if they are more likely to stay in treatment and take ownership of their treatment, he says.

Secondary outcomes will examine any proactive steps the patients take while in outpatient treatment, such as pursuing medication treatment or a medication evaluation.

Schoen emphasizes that in demonstrating to patients that they have choices, it also will be important to communicate through the characters that the first option doesn't always work for each person. “Some things won't be a fit,” he says. “You don't hit it out of the park your first time at bat.”

He hopes the novel series will prove to be a model for accessible evidence-based approaches that can be implemented with little clinical training. “There is a big push for evidence-based practice, but there are not a lot of people out there saying, 'Here's how you do it,'” says Schoen. “We need something new. We need a fresh way of looking at things.”