A practical clinical trial of coordinated care management to treat substance use disorders among public assistance beneficiaries
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This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

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A practical clinical trial of coordinated care management to treat substance use disorders among public assistance beneficiaries.

Morgenstern J., Hogue A., Dauber S. et al.
Journal of Consulting and Clinical Psychology: 2009, 77(2), p. 257–269.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Morgenstern at jm977@columbia.edu.

Further demonstration from a US research team that relatively intensive case management support does help welfare applicants overcome substance use problems, but in this case only those not already managed through substitute prescribing.

Summary This US study was designed as a practical clinical trial maximising real-world applicability The case management functions at issue were delivered by an existing clinical programme supported by welfare funding, treatment fidelity was assessed with quality assurance methods, research assessments minimally intruded on routine care, and outcomes were used which were measurable in routine clinical care via self-report and biological confirmation. while maintaining research integrity. It was implemented in partnership with a large city welfare agency. Participants were 421 substance using single adults and adults with dependent children applying for welfare benefits. They were selected from 1519 such applicants on the basis of their reporting a substance use problem and being motivated to receive treatment. Initially they had been identified by welfare workers using a standard screening A modified version of the CAGE screening questionnaire. questionnaire. Depending solely on where the next assessment slot was available, the workers transferred substance users for further assessment at one of the two offices in the study.

One of the offices offered usual assessment and care services: assessment by an addiction counsellor focused on substance use problems in relation to employability, followed by allocation to a generic welfare worker whose role was to assess eligibility for welfare payments and deal with non-compliance with the welfare system's requirements. They also referred the beneficiary to services, but only during infrequent meetings limited by a large caseload.

At the other office, more rounded and detailed assessments were conducted by a multidisciplinary team. Of psychiatrists, psychologists, social workers, nurses, vocational rehabilitation specialists, and addiction counsellors. After referring applicants to a range of services to meet identified needs, they transferred them to case managers. Their role was to maintain intensive contact Aided by relatively small caseloads, they contacted each client at least twice a week and visited them at their treatment programme every fortnight. They also familiarised themselves with local services, withdrawing clients from those not serving their needs, and cutting referrals to underperforming programmes. with the beneficiary and with the agencies providing them with services, and to ensure that these agencies matched the individual's needs and performed acceptably. In the usual care option, quarterly reassessments focused on welfare system requirements, but in the case management option the focus was on client progress and adjusting the service mix accordingly.

All 108 applicants who were in methadone maintenance treatment during the study were already in this treatment The study says that all clients in methadone maintenance were already enrolled in a programme when they entered the intervention, and transfer to another service was difficult and hence unlikely to occur. at the time they applied for benefits, and generally simply continued. Beyond these existing methadone patients, there were few if any heroin dependent applicants who might benefit from initiating treatment. Welfare case workers had more latitude to initiate or change other sorts of substance use treatments.

Diagnostic interviews found that about 6 in 10 of the sample met criteria for substance dependence, A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
• Tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve Intoxication or desired effect;
markedly diminished effect with continued use of the same amount of the substance.
• Withdrawal, as manifested by either of the following:
the characteristic withdrawal syndrome for the substance;
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
• The substance is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use.
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
mainly in respect of cocaine, alcohol or heroin, and another fifth for substance abuse. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
• Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (eg, repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household).
• Recurrent substance use in situations in which it is physically hazardous (eg, driving an automobile or operating a machine when impaired by substance use).
• Recurrent substance-related legal problems (eg, arrests for substance-related disorderly conduct).
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (eg, arguments with spouse about consequences of intoxication, physical fights).
Psychological problems and criminal justice involvement were common. About 1 in 6 had some degree of responsibility for dependent children.

% non-methadone clients abstinent from drugs and alcohol

As intended, over the year of the follow-up period, case managed clients saw their case workers more often than their counterparts in usual care. Especially during the first three months, they also received a broader range of services. However, this was entirely due to greater service access among clients not already in methadone maintenance. When usual care was replaced with relatively intensive and proactive case management, these non-methadone clients were significantly more likely to be in (drug-free) substance use treatment and to get help with medical, employment, mental health and basic needs. They also achieved significantly higher rates of abstinence Based on the clients' own accounts, which were overwhelmingly in agreement with the results of urine and hair sample tests. Similar differences between the groups were found when urine tests were relied on as indicators of abstinence. from alcohol and illegal drugs chart. Once other influences had been taken in to account, for every four people who were abstinent during any given month in the follow-up period, another three achieved this with the help of more intensive case management. This advantage emerged early In fact, seemed to be emerging even before the intervention started. However, the researchers conducted analyses which indicated that pre-baseline differences in abstinence rates were probably due to random fluctuations, and that even taking these differences in to account, the case management option resulted in greater abstinence rates. in treatment and was sustained throughout the follow-up period. In contrast, and just as with services received, abstinence rates among clients already in methadone treatment were not increased by case management.

Four in ten of the non-methadone clients were already in treatment, and largely were applying for benefits to help pay for it. Given this, the researchers argued that not only did their study demonstrate the value of case management for welfare applicants, but also for poor clients in publicly funded treatment in general.

Findings logo commentary The study deliberately selected the most promising candidates The 421 clients in the study were whittled down from 8986 applicants screened positive by welfare workers for substance use and sent for more comprehensive assessment. Over 1800 did not turn up for assessment. The remainder were sampled on a quasi-random basis by the research project's interviewers. Fewer than a third of this sample were selected for the study. Selected applicants were assessed as problem substance users motivated to attend treatment, who did not face major barriers such as serious mental illness or impending/actual homelessness. As intended, these selection processes would have resulted in a sample willing to accept both assessment and treatment, and potentially in a position benefit from that treatment. Indeed, just over half were already in treatment. for substance use treatment. Its results cannot be assumed to generalise to the bulk of welfare applicants identified by front-line welfare workers as potentially hindered by their substance use, but who do not have a serious problem, have one but are unwilling to acknowledge it, or are not motivated to tackle it. More information on the sample can be found in an earlier report.

Findings were line with a sparse evidence base suggesting that increased provision/receipt of welfare and medical services improves outcomes from addiction treatment. Lack of impact among methadone-maintained patients was expected because at the start of the study they were already in a treatment which entailed regular clinical and counselling contacts, leaving in this respect little for case managers to improve on. Had case managers been able to initiate methadone treatment, the picture might have been reversed, with greater impacts among those introduced to methadone programmes. It does however remain puzzling why the methadone patients in the study did not access the social, medical and welfare services made available through the case managers, services generally underprovided by US methadone programmes. Despite intensive case management contact, for these patients the status quo applied. The assumption may have been that simply turning up for methadone was sufficient engagement with treatment, and/or that patients on methadone could not take advantage of reintegration opportunities. Certainly the US requirement for long-term supervised consumption would constrict vocational and employment opportunities.

The same research team had recently conducted a similar study among substance-dependent mothers applying for benefits for families in need. Those offered case management were over twice as likely to be abstinent during any particular month in the two-year follow-up period, and across this period were 68% more likely to be in full time employment.

These two studies from in and around New York are at odds with the general picture reported recently in a review of studies of case management for drug users. Across 11 studies which randomly allocated clients to case management versus 'usual care', case management did improve access to services, but there was no statistically significant impact on illegal drug use. Results varied substantially from study to study, suggesting that effectiveness depends on the circumstances. One of the few reviewed studies which did report significant impacts on drug use was the study described Based on an earlier report than the one cited above: Morgenstern J. et al. "Effectiveness of intensive case management for substance-dependent women receiving Temporary Assistance for Needy Families." American Journal of Public Health: 2006, 96(11), p. 2016–2023; http://dx.doi.org/10.2105/AJPH.2005.076380. in the previous paragraph. The authors argued that their studies may have bucked the generally negative trend because the interventions they tested were robust, well resourced by the providing authority, and there was a clear divide between these services and those provided to comparison groups. Other factors include whether services are so easily accessible that case management is unnecessary, or so hard to access that case management cannot help (or not until new systems/resources have been developed), and the type and intensity of the case management model. Evidence is strongest for the strengths-based model which focuses on the client's strengths, abilities and assets, and puts them in control of setting goals and obtaining resources to achieve those goals.

Government-backed legislation currently being debated in Britain would introduce a welfare-to-work model closer to the US model, in particular making welfare benefits for problem drug users conditional At this time the plans are going through the parliamentary process. This element of the plans is being resisted by the Scottish government (Macleod A. "SNP rejects plan to cut benefits for drug addicts" The Times: 14 December 2008 http://www.timesonline.co.uk/tol/news/uk/scotland/article5342246.ece). on engaging with and making progress in the rehabilitation plan agreed with (or determined by) their employment adviser. There is though as yet no commitment to provide intensive case management support. Without this, the risk is that problem substance users and their families will be disproportionately subject to sanctions for non-compliance rather than make progress in their recovery. Even if Britain did adopt a case management model, the UK caseload may react differently to the applicants in the featured study. The US sample was dominated by cocaine users and it was among these and other non-opiate users (mostly drinkers) that positive effects were noted. All or nearly all the heroin dependent applicants in the sample were among the group on methadone who did not profit from case management. In contrast, at least initially The draft legislation includes a provision to extend the act's requirements to drinkers. in Britain, heroin users are likely to form the bulk of welfare applicants considered appropriate for treatment. If they are already in treatment, the featured study suggests that it will take a highly intensive, resource-rich and ambitious case management programme to take them further along the road to reintegration and employment. If they are not already in treatment, it may be because they are unable or unwilling to take up the treatment opportunities currently available. Again intensive work may be needed to overcome these obstacles. Such UK evidence as there is suggests that drug users not already in treatment will be among the welfare applicants least likely to comply with requirements in response to threats of benefit cuts.

Thanks for their comments on this entry in draft to Nicola Singleton of the UK Drug Policy Commission. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 08 May 2009

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