Researchers in Chicago apply an old medical maxim: "Chronic diseases require chronic cures."
By Lori Whitten, NIDA NOTES Staff Writer
Supplementing regular recovery checkups with motivational interviewing and active linking to treatment can get relapsing patients back into treatment sooner and help them stay longer, report NIDA-funded researchers. In the 2 years following treatment, patients who received the additional interventions were three times as likely to reenter treatment as others who received assessments only.
Lead investigator Dr. Christy Scott and coinvestigator Dr. Michael Dennis developed the effective intervention, which they call the Recovery Management Checkup (RMC) system, to expedite the recovery of people who had attended treatment and were now living in the community and experiencing substance abuse problems. They say the findings suggest that their approach to treating substance abuse as a chronic condition may help patients shake off the shame of relapse. "By the time patients had participated in checkups for 2 years, many who were initially reluctant to reenter treatment would call a peer to link them with help after a slip," says Dr. Scott, of Lighthouse Institute in Chicago, a Division of Chestnut Health Systems, Inc.
INTERVENTION MATCHES RELAPSE PATTERNS
In developing the RMC system, the researchers built on previous studies in which they had identified patterns of chronic substance abuse, relapse, and recovery. They found that, during the first 3 years after treatment, people frequently transitioned between recovery, substance abuse, and treatment—a cyclic pattern suggesting that periodic checkups, with intervention when necessary, might help shorten relapse episodes. They also researched approaches used to manage other chronic health conditions and found that monitoring for relapse and reducing the time from relapse to treatment reentry improved long-term outcomes.
To implement the RMC system, Drs. Scott and Dennis hired and trained a cadre of research assistants and linkage managers, many of whom were local recovering individuals. Chestnut staff and clinical colleagues at Haymarket Center, the largest addiction treatment provider in Illinois, interviewed 448 men and women who had met the standard criteria for a substance abuse diagnosis at some time in their lives, had abused alcohol or other drugs in the past 90 days, were not in protective custody, and intended to live in Chicago for the next year. Cocaine, alcohol, opiates, and marijuana were the most commonly abused drugs. Immediately following the interview, patients received a referral to Haymarket Center for treatment—60 percent as residents and 40 percent as outpatients—for 27 days, on average; 11 percent remained in treatment for 90 days or more. Upon leaving treatment, each patient scheduled eight quarterly followup appointments. Before the first checkup, researchers randomly assigned the patients to either the RMC intervention or an assessment-only control group.
At each checkup appointment, patients met with a research assistant. The assistant administered a 45-minute version of the Global Appraisal of Individual Needs assessment and ascertained information about the patient's living situation and substance involvement. If the patient had not abused any substance during the past 90 days, the assistant encouraged continued abstinence and scheduled the next appointment. Patients who reported slips were merely advised to reenter therapy if they were in the control group, but met with a linkage manager if they were in the intervention group and living in the community.
The linkage manager conducted motivational interviews, usually lasting less than 30 minutes, in which he or she provided feedback on patients' substance abuse and related problems, discussed ways to work through barriers to treatment reentry, and considered motivations to return to therapy. If a patient was willing to reenter treatment (even with low motivation), the linkage manager scheduled an appointment, telephoned with a reminder, and arranged transportation. The linkage manager provided assistance for 2 weeks, but afterward, responsibility for continuing therapy fell to the patient. Between RMC appointments, the patient received cards and calls from the research office; these served as a reminder of the next visit and carried a message of support from the research team.
CHECKUPS BOOST CHECK-INS
The researchers were able to interview patients at both the beginning and end of a quarter in 87.5 percent of cases. They categorized each patient's current status as in the community abusing substances, in treatment, in recovery (no substance abuse, problems, or treatment while living in the community), or incarcerated. Between the beginning and end of each quarter, about one-third of the patients, on average, transitioned from one status to another. Most (82 percent) transitioned at least once during the study, with 62 percent moving between points several times (see chart).
Among patients who relapsed, 67 percent of RMC patients reentered treatment within 90 days after the checkup, compared with 51 percent of assessment-only patients. RMC patients returned to treatment sooner (27 versus 45 days) and stayed in treatment longer (7.75 versus 4.68 days), on average, than the control group. Length of treatment predicted transition to recovery at the next quarterly assessment—for every 10.5 days in treatment, a patient was 1.2 times more likely to be abstinent at the next quarterly checkup.
"The checkups help a patient evaluate his or her behavior and recovery-related issues—much as a person with diabetes would report on blood sugar levels and diet and exercise patterns," says Dr. Thomas Hilton of NIDA's Division of Epidemiology, Services and Prevention Research. "By employing individuals in recovery as linkage managers, the program also offered an opportunity for the patient to return to treatment or at least receive support from someone who has been there."
Drs. Scott and Dennis plan to tailor the checkups for specific populations—for example, women involved in the criminal justice system. Treatment providers who want to implement the checkups can contact Dr. Scott (email@example.com).
Scott, C.K.; Dennis, M.L.; and Foss, M.A. Utilizing recovery management checkups to shorten the cycle of relapse, treatment reentry, and recovery. Drug and Alcohol Dependence 78(3):325-338, 2005.
Volume 20, Number 6 (July 2006)