Study: Healthcare Utilization Rates After Treatment Are Equivalent Among Abstinent and Low-Risk Drinkers

A fascinating new study will add to the small, but growing, treatment literature suggesting that low-risk drinking is a viable option for people receiving treatment for alcohol-use disorders. The paper, published this month in Alcoholism: Clinical and Experimental Research, measured healthcare utilization rates and associated costs over a 5-year period among clients receiving treatment in a large Northern California healthcare system. The results show that outcomes for abstainers and lower-risk drinkers were equivalent (and far better than the high-risk drinkers), despite the fact that the abstinence-based treatment received by all groups was the same.

According to the authors, "The finding that lower-risk drinkers did not differ from those of abstinent individuals, in inpatient use in particular, even when controlling for patient characteristics, suggests that a health policy perspective may consider benefits of lower-risk drinking."

Here's the abstract via Wiley:

Background

Lower-risk drinking is increasingly being examined as a treatment outcome for some patients following addiction treatment. However, few studies have examined the relationship between drinking status (lower-risk drinking in particular) and healthcare utilization and cost, which has important policy implications.

Methods

Participants were adults with alcohol dependence and/or abuse diagnoses who received outpatient alcohol and other drug treatment in a private, nonprofit integrated healthcare delivery system and had a follow-up interview 6 months after treatment entry (N = 995). Associations between past 30-day drinking status at 6 months (abstinence, lower-risk drinking defined as nonabstinence and no days of 5+ drinking, and heavy drinking defined as 1 or more days of 5+ drinking) and repeated measures of at least 1 emergency department (ED), inpatient or primary care visit, and their costs over 5 years were examined using mixed-effects models. We modeled an interaction between time and drinking status to examine trends in utilization and costs over time by drinking group.

Results

Heavy drinkers and lower-risk drinkers were not significantly different from the abstainers in their cost or utilization at time 0 (i.e., 6 months postintake). Heavy drinkers had increasing odds of inpatient (p < 0.01) and ED (p < 0.05) utilization over 5 years compared with abstainers. Lower-risk drinkers and abstainers did not significantly differ in their service use in any category over time. No differences were found in changes in primary care use among the 3 groups over time. The cost analyses paralleled the utilization results. Heavy drinkers had increasing ED (p < 0.05) and inpatient (p < 0.001) costs compared with the abstainers; primary care costs did not significantly differ. Lower-risk drinkers did not have significantly different medical costs compared with those who were abstinent over 5 years. However, post hoc analyses found lower-risk drinkers and heavy drinkers to not significantly differ in their ED use or costs over time.

Conclusions

Performance measures for treatment settings that consider treatment outcomes may need to take into account both abstinence and reduction to nonheavy drinking. Future research should examine whether results are replicated in harm reduction treatment, or whether such outcomes are found only in abstinence-based treatment.

Figure 1 shows Adjusted odds ratios of utilization by 6-month drinking group over time:

Figure 2 shows Adjusted average costs per member month by 6-month drinking group over time:

                                               






As mentioned above, these are the results from patients who attended abstinence-based treatment. It will be
interesting to see if these results are replicated among patients who are instructed on low-risk drinking. What experience do readers have with this issue? Do results like these make those directing abstinence-based programs think twice about the policy? It would be great to hear from you.

Hat tip: Thanks, Dr Reid Hester, for bringing this study to our attention.

Source: Kline‐Simon, A. H., Weisner, C. M., Parthasarathy, S., Falk, D. E., Litten, R. Z., & Mertens, J. R. (2013). Five‐Year Healthcare Utilization and Costs Among Lower‐Risk Drinkers Following Alcohol Treatment. Alcoholism: Clinical and Experimental Research.
http://onlinelibrary.wiley.com/doi/10.1111/acer.12273/abstract

Study: Looking for the uninsured in Massachusetts? Check opioid dependent persons seeking detoxification

An interesting study from Drug and Alcohol Dependence cites the rate of uninsurance at a large Massachusetts detox program as 23% in the 2013 sample they observed (five years after the insurance mandate). That's nearly five times higher than the state average of 4.8%. The authors highlight correlates of being uninsured (table below), which include being young and being male (expected), but also having a higher level of education (unexpected). Finally, more than half of the uninsured participants in the study had been so for more than one year, highlighting the ongoing need for outreach and education about public programs.

Here is the abstract via ScienceDirect:

Abstract

Background

We examined the rate of uninsurance among persons seeking detoxification at a large drug treatment program in Massachusetts in 2013, five years after insurance mandates.

Methods

We interviewed three hundred and forty opioid dependent persons admitted for inpatient detoxification in Fall River, Massachusetts. Potential predictors of self-reported insurance status included age, gender, ethnicity, employment, homelessness, years of education, current legal status, and self-perceived health status.

Results

Participants mean age was 32 years, 71% were male, and 87% were non-Hispanic Caucasian. Twenty-three percent were uninsured. In the multivariate model, the odds of being uninsured was positively associated with years of education (OR = 1.22, 95%CI 1.03; 1.46, p < .05), higher among males than females (OR = 2.63, 95%CI 1.33; 5.20, p < .01), and inversely associated with age (OR = 0.94, 95%CI 0.90; 0.98, p < .01).

Conclusion

Opioid dependent persons recruited from a detoxification program in Massachusetts are uninsured at rates far above the state average. With the arrival of the Affordable Care Act, drug treatment programs in Massachusetts and nationally will be important sites to target to expand health coverage.

And here's a table from the report:

Correlates of Being Uninsured (n = 340).

Correlate	Unadjusted OR (95%CI)	Adjusted OR (95%CI)
Age	0.95** (0.91; 0.98)	0.94** (0.90; 0.98)
Gender (Male)	1.98* (1.07; 3.69)	2.63** (1.33; 5.20)
Non-Hispanic Caucasian (Yes)	2.48 (0.94; 6.54)	2.30 (0.83; 6.41)
Homeless (Yes)	0.38 (0.11; 1.29)	0.33 (0.09; 1.21)
Employed Part- or Full-Time (Yes)	1.09 (0.49; 2.42)	0.77 (0.32; 1.89)
Education (Years)	1.16* (1.01; 1.33)	1.22* (1.03; 1.46)
Pending criminal charges (Yes)	1.03 (0.58; 1.82)	0.92 (0.51; 1.65)
Perceived Health	0.71* (0.54; 0.93)	0.78 (0.58; 1.05)

* p < .05, **p < .01

http://www.sciencedirect.com/science/article/pii/S0376871613005322

Health Care Changes Important to Addiction Treatment

Among the various things I do, I work about half time for a large health care organization (HCO) in Minnesota called Allina Health. Currently Allina is the largest HCO in Minnesota, but it is likely to become the second largest due to continuing consolidation in HCOs. HealthPartners and Park Nicollet, two other HCOs in Minnesota desire to merge, and it does not appear that there will be any barriers from either the MN Attorney General or federal agencies. So it is likely to proceed, which would produce a larger HCO than Allina. Consolidation in health care is almost a torrent right now. It's happening very rapidly. In the Twin Cities area in Minnesota, there are almost no independent primary care practices; they've all been purchased by large HCOs. The health plans like Blue Cross/Blue Shield and HealthPartners are working very closely with the large HCOs to create products that maximize value to the consumer. So the future of health care is one dominated by a few large HCOs that dominate a market. Unfortunately, this is all to familier. Witness the consolidation in airlines and in cable television, internet and wireless services.

But there are important changes in perspective that will drive a much more pronounced and determined effort to deal with behavioral health issues, including both mental health and addiction. The most important of these is the movement from fee for service to capitated approaches. In fee for service, a clinician is paid a specific amount for providing a service, such as a primary care visit or an addiction counseling session. This rewards providing more services for fewer people, and it drives up costs without regard to quality or outcomes. Increasingly, health plans are moving towards a different model where the HCO is accountable for outcomes, not just whether the service was delivered. In a capitation model, a HCO is given a single fee for treating someone with a given diagnosis. It is up to the HCO to figure out how to do this efficiently and effectively.

This is a good thing. Here's an example. Someone with an addiction goes to a time-limited, intensive rehab program, which is the current standard of care. Let's say that this intensive outpatient program costs $2400. Someone else who was able to produce equivalent outcomes for $1800 would be attractive to a health plan, not to mention someone paying out of pocket. Similarly, a $15,000 or $20,000 residential treatment program would go out of business if it could not produce substantially better outcomes than someone providing office-based treatment for a third of that amount. I think this is quite possible to do, since there is no demonstrated benefit to residential treatment. There is room here for innovation, for modernizing our approach to addiction treatment. It's time for addiction treatment providers to take responsibility for the outcomes of their treatment. It's time to end the idea that treatment failures are the patient's fault. In the future, this isn't going to fly. One of my goals is to make sure this happens. We can generate better outcomes at much less cost.

What if, instead of being paid $30,000 for a residential treatment lasting 28 days regardless of whether that actually produced a good outcome, HCOs were only paid for treatment that worked? What if payment was based on outcomes rather than the treatment provided? I can tell you, that would change the addiction treatment world in a heartbeat. Give patients that same treatment over and over even though it's already proved ineffective? No way! Give everybody the same treatment whether they need it or whether it's been shown to improve outcomes? Forget about it? Changes in how payment is made for services will force change in the treatment delivered. And it's about time.

What's the silver lining? We can lead the way. Many of the very high utilizers of health care have addiction and mental health problems. We have to figure out ways to improve their care and outcomes. That's our challenge and our opportunity.

MW

Living With Success and Failure in Treating Addiction

A number of my recent postings have focused on chronicity, treatment-resistant disease, and staying connected with people who are not doing well no matter what. These are important principles to me and to others who are dedicated to helping people with addictions overcome them if possible, but to continue to work with them if it is not. It is so important to talk about this, to advocate for this, because too often people who have addictions unresponsive to current treatment are condemned, abandoned by their families and friends in the guise of "tough love," prosecuted for crimes and imprisoned, unemployed and homeless because background checks reveal a criminal history. They deserve our care and compassion in spite of, indeed because of, their plight. This service is informed by our humility in the face of a difficult, complicated problem that too often defies effort, faith and science.

However, I witness a lot of successful outcomes, and I need to share those too. As an addiction psychiatrist, I don't see run-of-the-mill patients, I see those with multiple, usually chronic, addictive, mental and physical disorders who have failed to respond to multiple rehabs, or to other approaches. Many patients are referred from hospital based physicians who are seeing the most treatment-refractory group of patients with addictions.

But most of the time, a change in antidepressants, treating a previously undiagnosed disorder, or changing pain medication makes positive difference. Sometimes it is dramatic. I've had patients with chronic pain who were on the edge of despair, even suicide, whose lives turned around dramatically by simply changing the pain medication. Others have depression, anxiety, post-traumatic stress disorder or borderline personality disorder, but where a sophisticated diagnosis and change in treatment results in dramatic improvement.

For most of us, I think our challenges are more salient, bothering us. We fell short. We didn't solve the problem. We failed our patients. But in the majority of cases, we can make a difference. Sometimes that difference is relatively small but meaningful. For example, one patient was able to pick up her grandchild for the first time because of adjustments in pain medications. Another one was able to establish and maintain long-term sobriety for the first time because of a combination of psychotherapy and anti-relapse medications over a 3 year period (but not without some early recurrences.)

Last week, a colleague of mine, a very compassionate family physician called me. He is seeing a patient who has several ongoing chronic illnesses, one of which is alcohol dependence. In spite of everything he and others, including his physician, have tried, he continues to struggle with his drinking. My colleague called to ask, "Am I enabling? Should I send him away, somewhere else?"

My answer came from my own experience more than 25 years ago: "Who is better situated than you to stay with him, and continue to work with him to overcome his disease? Do you discharge people with diabetes, heart disease or arthritis because their disorders don't respond to treatment? How would it help him get better if you were to abandon him? Isn't he demoralized enough by his own 'failure' to respond to treatment?"

He was grateful for my advice and support, and then he added, "I feel like I'm all alone out here [in my primary care clinic.]" I told him I understood, I felt the same way.

Recovering from Recurrent Episodes

Several of my patients had recurrences of their addictions this week. Each one of them struggled mightily with feelings of shame and guilt. "Why do I keep doing this? I'm a smart person, I know what's going to happen. And I was doing so well!" My response in each case was different of course, and depended upon that particular person's situation, disorders, severity, past history, and so on. But here are some common things I do pretty much every time:

1. Stopping suddenly and permanently is a rare outcome, with or without treatment or rehab or AA. In one study that followed people with alcohol dependence for 10 years following an episode of treatment the proportion of people remaining continuously abstinent for the entire period was 8%. So the norm is to struggle with recurrences.

2. Most people take several years of persistent effort to finally establish long-term remission, on average 5-10 years. The most important thing is to keep working at it.

3. I've begun thinking in terms of "quit attempts," much as with smoking. How many times do most of us have to "stop" before it sticks? And even then, recurrence is common even years later.

4. Think of other types of behavior change. How often do any of us make a decision to eat better/less,  get more exercise, work less, work more, keep going at my meditation practice, try to be a better person, etc? And how often does that go smoothly, without slips and slides backwards? Almost never. So why would it be any different for changing substance use behavior?

5. The notion of counting sober days/months/years, sober dates, etc., is usually not helpful and may be harmful. So is the notion of "starting from scratch" after a recurrence. Every sober day is a sober day. Think more in terms of drinking or using days per month or 6 months or a year. Often I'll ask my patients to estimate the number of drinking or using days in the 6 or 12 months prior to starting treatment with me, and usually the answer is 90-100% of the days, or something like 180 days out of 180 days. Then, if they have had a period of remission, I'll ask how many drinking/using days they've had in the last 6 months, and often the answer is 3, or 5. So, 180 compared to 3. Is that an improvement? And nothing can take away those days of remission.

6. If we used the same outcome criterion for other disease as we do for addiction, here's how it would look:

• Someone with asthma should never have another asthma attack the rest of their lives
• Someone with high blood pressure should never have another reading above 140/90 the rest of their lives
• Someone with depression should never have another episode.
• Someone with cancer who is in remission for 3 years and then has a recurrence demonstrates a complete failure of treatment, and that period of remission is worthless.
• If permanent and complete remission is not obtained in any of these disorders, treatment is a complete failure. That is improvement but not complete and permanent remission is meaningless.

These example demonstrated the absurdity of the way we think about outcomes in substance use disorders. How about this alternative approach: the goal of treatment is to minimize the frequency, severity, length and consequences of recurrences. 

7. The worst thing one can do after a recurrence is to not learn from it. I ask my patients to reframe this experience thus: we have to examine how the relapse occurred, in order to understand how this disease works in you. It's different in everyone. But by examining recurrences, we can develop better approaches to prevent the next one.

8. Finally, it's not helpful to get distracted by shame and guilt. Recurrences happen. Stop it quickly, learn from it, pick yourself up, and move on. Look to the future, look to preventing the next one. 

MW