Choosing the Optimum Treatment Setting for Those with Alcohol Use Disorders Robert G. Rychtarik, Ph.D. Department of Psychiatry
Financial Disclaimer There are no financial conflicts to disclose.
Goals • Historical background on the use and efficacy of different treatment settings for AUD • Summarize findings our own work at RIA (Rychtarik et al., 2000) • Present results of our effort to replicate this work at ECMC (Rychtarik et al., 2017)
Key Questions 1. Does Inpatient Treatment for AUD Produce Better Outcomes that Outpatient Treatment for All Comers? a) If so, how big is the advantage?
Key Issues (Continued) 2. Does Inpatient Treatment for AUD Produce Better Outcomes than Outpatient Treatment Among Identifiable Subgroups of Clients? a) If so, how big is the advantage?
Acknowledgments Research Staff Research Collaborators Carrie Pengelly Neil B. McGillicuddy, Ph.D. Jean Finn Robert B. Whitney, M.D. Dennis Dickman Gerard J. Connors, Ph.D. Kathy Skibicki George D. Papandonatos, Ph.D. Sue Sperrazza Clinical Coordinator Rebecca Eliseo-Arras Joan Duquette Joe Hoffman Florence Leong Larry Jagodzinski Eileen Logsdon Pat Aughtry Barb Roth
Special Acknowledgements • Erie County Medical Center (ECMC) Division of Chemical Dependency • National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Background • Mid-late 1980s reviews: • Outpatient (OP) = Inpatient (IP)
American Psychologist, 41, 794-805.
The Practical Effect on Programs Available 90% 80% 70% 60% Inpatient/Residential 50% programs 40% Outpatient programs 30% 20% 10% 0% 1990 2002 Source: McLelland (2006)
Finney & Moos (1996) Percentage of Days Abstinent Inpatient Outpatient Month
Revisiting Inpatient Care • Have we thrown the baby out with the bathwater? • Has the pendulum swung to far toward outpatient treatment for all?
Lingering Question • Do some individuals still benefit more from inpatient than outpatient care? • Higher Problem Severity? • Lower Cognitive Functioning? • Higher Psychiatric Severity? • Lower Social Support Abstinence? • Lower Motivation?
The RIA Study
Our Early Work • RCT • RIA’s Clinical Research Center • Manualized treatment components • Randomization to treatment staff • Recruitment by advertising
Design Features • N = 192 • Randomized treatment groups to: • 28-day inpatient treatment + 6 mos. of aftercare • 28-day intense outpatient + 6 mos. of aftercare • 28-day standard outpatient + 6 mos. of aftercare
Hypotheses • Tested two a priori Client Attribute X Setting interaction hypotheses: • Problem Severity: • Higher Severity would benefit from Inpatient • Lower Severity would benefit from Outpatient • High network support for drinking would be associated with better outcomes in Inpatient
Exploratory Client Attributes • Explored moderating effects of other Client Attributes: • Cognitive Functioning • Psychiatric severity • Self-efficacy • Motivation
Problem Severity Attribute • Alcohol Use Inventory, General Alcohol Involvement Scale score (AUI-AIS; Horn et al., 1990)
Alcohol Involvement X Setting Interaction
Alcohol Involvement X Setting Interaction
Exploratory Client Attributes • Explored moderating effects of other Client Attributes: • Cognitive Functioning • Psychiatric severity • Self-efficacy • Motivation
Cognitive Functioning Attribute • Symbol Digit Modalities Test (SDMT; Smith, 1982)
Cognitive Functioning X Setting Interaction
Involuntary Abstinent Days (Hospitalizations & Incarcerations) 25 20 15 Percentage 10 5 0 Inpatient Intenstive Outpatient Standard Outpatient
Summary of RIA Study Findings • Lower AUD Severity: OP = IP • Higher AUD Severity: IP > OP • Lower Cognitive Functioning: IP > OP • Involuntary Abstinent Days: IP < OP
The ECMC Study
Can we replicate these findings in the real-world setting of a community-based substance abuse treatment program?
Aims • Primary aims: • Recruit through ECMC clinics & detox • Prospectively categorize clients as to need for inpatient care using prior study’s cut -points • Need for IP: High Severity or Low Cognitive Level • No Need for IP: Low Severity and Higher Cognitive Level
RIA Study versus ECMC Study RIA Study ECMC Study Location RIA ECMC Inpatient & Outpatient Clinical Research Center Chemical Dependency Programs Recruitment Source Media advertisements ECMC Clinics & Detox. Unit Treatment Staff Randomization YES NO Manualized Treatment Components YES NO Treatment fidelity monitored YES YES* Standardized treatment intensity YES YES Randomization to setting YES YES Treatment free of charge to client YES YES Blinded Research Assessments YES YES 18-month follow-up YES YES
Treatment Intensities Inpatient Outpatient Inpatient Days 21 - Outpatient Sessions (21 days) - 6 24 24 Aftercare Sessions (6 months)
Sample Characteristics Inpatient Outpatient (N = 84) (N = 92) M SD M SD Age (years) 40.89 10.36 40.40 9.35 Gender (% female) 26 27 White race/ethnicity (%) 66 61 Employed full time (%) 26 26 Education (years) 12.06 1.75 12.24 2.15 Married/Cohabiting (%) 30 30 ECMC clinic source (% Detox) 46 53 Prior inpatient ADT (%) 52 57 Prior outpatient ADT (%) 63 73
Client Attributes Inpatient Outpatient (N = 84) (N = 92) M SD M SD AUI Alcohol Involvement 33.11 13.34 33.11 12.94 SDMT 43.60 10.69 42.52 10 26
Monthly 12-Month Baseline Drinking-Related Measures Inpatient Outpatient (N = 84) (N = 92) M M % Voluntary alcohol abstinent days/mo. 31.55 27.49 % Voluntary alcohol/drug abstinent 22.35 22.02 days/mo. % Totally abstinent from alcohol/mo. 8.01 4.27 Drinks per drinking day 13.39 14.36 % Hospitalized/Incarcerated at least 1 13.98 11.50 day/mo.
Primary AUD Monthly Outcomes (over 18 mos.) • Percentage of Days Abstinent • Point Prevalence of Total Abstinence • Drinks Consumed on Days when Drinking
Secondary AUD Monthly Outcomes (over 18 mos.) • Point Prevalence of Any Hospitalization, IP/Residential Treatment, or Incarceration
What we found.
Partial Replication for AUD Severity • Percentage of Days Abstinent • Point Prevalence of Total Abstinence • Drinks Consumed on Days when Drinking
Drinks per Drinking Day
Drinks per Drinking Day
Treatment Expectancy (after randomization — before treatment) 6-item, 10-point scale rating their scheduled treatment on: 1. It’ s reasonableness 2. Their confidence in its helpfulness 3. Whether they would recommend it to a friend 4. How similar it was to that expected 5. The expected ease of participating 6. Their overall satisfaction with the treatment scheduled
Treatment Expectancies 8.4 8.3 8.2 8.1 8 7.9 7.8 7.7 7.6 7.5 7.4 Inpatient Outpatient
Percentage of Days Abstinent
Percentage of Days Abstinent
Percentage of Days Abstinent
Percentage of Days Abstinent
Point-Prevalence of Monthly Abstinence
Point Prevalence of a Subsequent Hospital Admission, IP Treatment, or Incarceration
Point Prevalence of a Subsequent Hospital Admission, IP Treatment, or Incarceration
Point Prevalence of a Subsequent Hospital Admission, IP Treatment, or Incarceration
Point Prevalence of a Subsequent Hospital Admission, IP Treatment, or Incarceration
Conclusions
Key Question #1 1. Does Inpatient Treatment for AUD Produce Better Outcomes that Outpatient Treatment for All Comers? a) If so, how big is the advantage?
Key Question #2 2. Does Inpatient Treatment for AUD Produce Better Outcomes than Outpatient Treatment Among Identifiable Subgroups of Clients? a) If so, how big is the advantage?
Remaining Issues 1. What is the optimum severity measure? 2. Why do inpatients do better initially? Why does the effect deflate over time? 3. Expectancy: Timing? Why only for inpatients? 4. Cost analyses?
Remaining Issues (Cont.) 5. Representativeness of the sample? 6. How would results be influenced by medication for AUD? 7. Results say nothing about treatment setting for AUD’d adolescents
Clinical Implications • Inpatient may still be the treatment of choice for those with more severe problems. • If a client has high expectations that inpatient is what they need, seriously consider giving it to them!
Thank You!
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