Integration demands highest standard of care

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.

McLellan believes if it were the addiction treatment field conducting this study, it would have stopped the research, purged anyone who was on medication, and then continued studying. However, these researchers were interested in finding the combination of things that would achieve blood pressure control.

For those who didn’t achieve blood pressure control by 6 months, the ALLHAT team re-randomized the groups, added a medication, and improved control from 42% to 55%. All patients who failed to achieve control within 12 months got a third medication. The rate of control rose to 64%.

“Quite literally at the same time that the NIAAA was hanging its head in shame for not seeing any matches in their study, the NHLBI (National Heart, Lung, and Blood Institute) was waving a flag of victory at not having seen any matches but having achieved a strategy for bringing improvement to patients,” McLellan continued.

Finding treatment that works

Throughout his research and observation, McLellan has seen many types of treatment fall short for patients. However, there are two populations that get the treatment that all should receive – doctors and airline pilots. “If you’re in either of those groups, you don’t get a quantitatively better kind of care, you get a qualitatively different kind of care,” he explained.

The process for this group goes as follows:

• A colleague may point out suspicious behavior such as an individual’s breath smelling of alcohol every afternoon, that the individual is making mistakes, or that he or she is missing information in a log.
• The individual is referred to the physician health plan (all but two states have one).
• The individual receives a complete evaluation and diagnosis. When an SUD is found, he or she is offered a choice: enter into the 5-year addiction treatment program OR become liable for any charges that may be brought as a result of the substance abuse. If the person chooses treatment, “all of that is held in abeyance.”
• There are three phases of the treatment program:

1. Evaluation

2. Acute care treatment, which is similar to what any other person would receive in treatment (30 to 60 days of residential care)

3. Six to nine months of outpatient care during which the professional may resume practice. Throughout this period and for four years after, the person is monitored continuously.

McLellan said that this type of treatment plan offers successful outcomes – it preserves jobs, increases abstinence. In a five-year monitoring period, 78% of physicians never give a positive urine sample. “And this isn’t at the end of five years when a sample is taken. This is throughout the entire five-year period,” he clarified.

Some assert that holding “regular people” to the same standards required of pilots and physicians is unfair. But in fact, McLellan says when pilots and physicians receive the same kind of treatment that “regular people” do, they experience the same relapse rates with the same antecedent causes.

As mental health and substance abuse services integrate into the rest of healthcare McLellan implored the field to utilize the right model and set sensible measures.

 “[Integration] is not a gift to the mental health and substance abuse field. We’re not being given something just because it’s fair, just because it’s our time, or just because there’s a Democratic administration. You can’t run the rest of healthcare if you don’t manage substance use and mental health.”

Tom McLellan, chief executive officer of the Treatment Research Institute, will join Michael Bottecelli of the White House Office on Drug Control Policy to address “21^st Century Behavioral Health Treatment and Delivery” at the 2014 National Council conference in Washington D.C. Addiction Professional will be there.