Results Summary
What was the research about?
Addiction is a treatable, long-term illness that affects a person’s brain and behavior. It leads to an inability to control the use of substances, such as drugs or alcohol. People with addiction continue to use substances despite the harm it causes. Treatment can be in different care settings, such as outpatient or residential programs.
The American Society of Addiction Medicine, or ASAM, created a standard approach to match patients to treatment. Patients answer a comprehensive set of questions about their withdrawal symptoms, physical and mental health, readiness to change, and chance of relapse. Questions also ask about living situation and relationships. Based on the responses, the ASAM approach suggests a treatment setting.
In this study, the research team wanted to learn whether using ASAM standards worked to help patients with addiction stay in treatment. The team compared data from patients in addiction programs in:
- 30 counties that began requiring use of ASAM standards, versus
- 28 counties that didn’t require ASAM standards
The research team also did surveys to look at patients’ experiences and the information received at the start of treatment.
What were the results?
Across treatment settings, counties that required ASAM standards had an increase in the number of patients who stayed in residential treatment programs for at least 30 days. But these counties had no difference in the number of patients who stayed in outpatient treatment programs.
In survey responses, compared with patients in programs that didn’t use ASAM standards, patients in programs that used them were more likely to report that the person asking questions discussed:
- Withdrawal symptoms and the need for management
- Reasons for and problems from continued substance use
- What might make it easier or harder to recover
- What they learned from patients’ answers to questions
- Treatment recommendations
Patients also understood more about their mental and physical health. They were more satisfied with their treatment setting choice. Patients didn’t differ in responses to other survey questions, such as whether staff listened carefully.
What did the research team do?
The research team used a database with information from patients treated at all addiction programs in California that had received public funding. All patients had Medicaid. The team looked at discharge and treatment records to compare counties.
To assess patient views, the research team surveyed 851 patients in addiction programs that did and didn’t use ASAM standards.
People with addiction, caregivers, addiction doctors, and patient advocates helped design the study.
What were the limits of the study?
The research team didn’t assign patients or counties by chance to use ASAM standards so factors other than the standards may have affected the results. The study took place in California. Results may differ for patients in other states.
Future research could look at how to help patients feel comfortable answering the comprehensive ASAM questions at the start of treatment.
How can people use the results?
Addiction treatment programs can use the results when considering ways to match patients with the treatment setting that works best for them.
Professional Abstract
Objective
To test county Medicaid program implementation of the American Society of Addiction Medicine (ASAM) criteria versus clinical judgment for determining level of care for people with addiction on treatment retention and on patient experience and receipt of information on treatment options
Study Design
| Design Elements | Description |
|---|---|
| Design | Observational: comparative interrupted time series |
| Population | California addiction treatment data from 407,871 discharges and 309,110 treatment episodes between 2015 and 2019; People were ages 18 and older with Medicaid coverage who had received treatment in a specialty addiction treatment program |
| Interventions/ Comparators |
|
| Outcomes |
Primary: treatment retention Secondary: patient experience and perceptions of information provided about treatment options |
| Timeframe | 30-day follow-up for primary outcomes |
This retrospective study compared the effect of ASAM versus non-ASAM-based intake assessments for determining addiction treatment level of care on treatment retention and on patient experience and receipt of information.
Researchers compared data from patients treated in 30 counties that required ASAM-based intake assessments versus patients treated in 28 counties that did not require such assessments. In ASAM-based assessments, clinicians use a standard interview guide to determine a level of care based on the patient’s risk rating on six biological, psychological, and social factors. In non-ASAM-based assessments, clinicians use an interview guide developed by the treatment center or based on the Addiction Severity Index and determine care based on clinician judgment.
Data came from an episode-level database with information about patients treated at all addiction programs in California receiving public funding, including Medicaid, Medicare, and county funding.
To assess patient experience, researchers surveyed 851 patients within seven days of the intake assessment.
People with addiction, caregivers, clinicians, and patient advocates helped design the study.
Results
Overall, treatment retention after 30 days did not differ between counties that required versus counties that did not require ASAM-based assessments. In residential care settings, counties that required ASAM-based assessments had increased treatment retention compared with counties that did not require them (p<0.05).
In the survey, compared with patients in programs that did not use ASAM-based assessments, patients in programs that used them were more likely to report that the intake assessor discussed (all p<0.01):
- Withdrawal symptoms and the need for management
- Reasons for and problems resulting from continued drug use
- What might make it easier or harder to recover
- What they learned about the patient’s addiction
- Treatment recommendations based on the assessment
Patients also understood more about their mental and physical health and were satisfied with their treatment setting choice (p<0.01).
Patient perceptions of some other aspects of the intake assessment, such as whether the intake assessor listened carefully, did not differ with significance between programs that did and did not use ASAM-based intake assessments.
Limitations
Researchers did not randomize patients or counties to ASAM versus non-ASAM intake assessment; factors other than the intake assessment could have affected the results. The study took place in California; results may differ in other states.
Conclusions and Relevance
In this study, ASAM-based intake assessments were associated with improvements in treatment retention in residential settings but not across all settings. Patients in programs that used ASAM-based assessments were more likely to report receiving information about level of care recommendations and being satisfied with their treatment choice than patients in programs that did not use them.
Future Research Needs
Future research could evaluate options for administering ASAM-based assessments with fidelity while accommodating patients’ emotional or physical state during intake.
COVID-19-Related Study
Examining How the COVID-19 Pandemic Affected Treatment for Addiction
Results Summary
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
What was this COVID-19 study about?
Addiction is a treatable, long-term illness that affects a person’s brain and behavior. It leads to an inability to control the use of substances, such as drugs or alcohol. People with addiction continue to use substances despite the harm it causes. The COVID-19 pandemic may have affected treatment for people with addiction.
In this study, the research team looked at whether fewer people in California started addiction treatment during the first months of the pandemic compared to before the pandemic. The team also looked at whether telehealth may have helped people get addiction treatment during the pandemic. In telehealth, patients visit providers via phones or computers rather than in person.
What were the results?
The number of people starting addiction treatment each month was 28 percent lower during the pandemic than before the pandemic. This decline was similar at outpatient and residential programs.
Declines may be due to fewer people seeking treatment. They may also be because prisons, courts, hospitals, and other community sources referred fewer people to treatment. Groups with large declines of 35 percent or more in starting treatment included people:
- Without Medicaid
- Younger than age 25 compared with people ages 25–44
- Whose main drug of use was cannabis
- Involved with the criminal justice system
- Recently released from prison
- Referred from a driving under the influence program, drug court, or another community source like their employer or child protective services
- Who had a hospital stay in the last month
In the first months of the pandemic, providers said that telehealth helped keep people in treatment. They also said telehealth may work better for some services than others. For example, telehealth worked well for counseling sessions. But they weren’t sure how well telehealth worked for visits to start medicine for opioid use disorder. Providers felt that telehealth may make it easier for some patients to get treatment, even after in-person care restarts.
What did the research team do?
The research team used a database with information from patients treated at all addiction programs in California that had received public funding. Data from before the pandemic was from January 2019 to February 2020. Data from during the pandemic was from March to October 2020.
During the first year of the pandemic, the research team surveyed addiction providers three times. Between 89 and 150 providers responded each time. Surveys asked how COVID-19 and telehealth use affected addiction treatment. The team also talked with 30 people about COVID-19 and addiction treatment. These people were addiction providers, government officials, and mental health staff. The team also talked with staff from emergency medical services and emergency room providers.
People with addiction, family members, addiction providers, and government officials helped plan and conduct the study.
What were the limits of the study?
The study looked at programs in California that focus on treatment for addiction. Results may differ in other states, or in other settings, like primary care.
How can people use the results?
Addiction providers and doctors can use the results when considering ways to support patients with addiction during public health emergencies.
Professional Abstract
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
Background
To reduce the spread of the coronavirus, many states issued shelter-in-place and social distancing policies. Addiction treatment specialists were concerned that these policies could make it difficult for people with addiction to initiate treatment.
Objective
(1) To determine whether the COVID-19 pandemic was associated with a reduction in addiction treatment initiation; (2) To determine the extent to which the use of telehealth mitigated pandemic-related barriers to addiction treatment
Study Design
| Design Element | Description |
|---|---|
| Design |
Retrospective study, survey, interviews |
| Population |
Retrospective study: Episode-level data for patients starting addiction treatment Survey: Wave 1 included 150 addiction treatment providers; wave 2 included 100 addiction treatment providers; wave 3 included 89 addiction treatment providers Interviews: 30 people familiar with addiction treatment programs |
| Outcomes |
Retrospective study: treatment initiation rates Survey and interviews: mitigation of barriers to addiction treatment during the COVID-19 pandemic |
| Data Collection Timeframe |
Retrospective study: January 2019–February 2020 versus March–October 2020 Survey and interviews: June 2020–February 2021 |
This retrospective descriptive study compared rates of treatment initiation among people with addiction during the COVID-19 pandemic with treatment initiation rates during the year prior to the pandemic. Researchers used data from an episode-level database that included information about patients starting treatment at all addiction treatment programs in California that received any public funding, such as Medicaid, Medicare, or grants. The team compared pre-pandemic data from January 1, 2019, through February 29, 2020, with pandemic data from March 1, 2020, through October 31, 2021.
To determine whether the use of telehealth mitigated barriers to treatment, researchers surveyed addiction treatment providers and interviewed 30 people familiar with addiction treatment delivery systems in California. Interviewees included 12 addiction treatment providers, 9 government officials, 4 behavioral health staff, 3 emergency medical services personnel, and 2 emergency department providers.
People with addiction, family members, addiction treatment providers, and government officials helped plan and conduct the study.
Results
Overall, monthly addiction treatment initiations were 28% lower during the pandemic than pre-pandemic. Treatment initiations at outpatient and residential treatment facilities had equivalent declines.
Groups with large declines in treatment initiation of 35% or greater included those:
- Without Medicaid coverage, younger than age 25 compared with those ages 25–44, or whose primary drug of use was cannabis
- With criminal justice involvement who were recently released from prison, referred from a driving under the influence program or drug court, referred from a community source including child protective services or an employer, or who had had a hospitalization within 30 days
Provider organizations reported pivoting quickly to telemedicine at the beginning of the pandemic. They stated that telemedicine significantly mitigated access barriers, particularly for existing patients, and suggested it may help patients access services even when no longer essential for reasons of safety. Providers indicated that delivering some services via telehealth, such as individual counseling, was more effective than delivering other services, such as intake assessments for medication to treat opioid use disorder.
Limitations
The study took place in specialty addiction treatment settings in one state. Results may differ in non-specialty settings or other states.
Conclusions and Relevance
In this study, the COVID-19 pandemic reduced the number of addiction treatment initiations in the state of California. Declines in treatment initiation may reflect both fewer people seeking treatment individually, and fewer referrals to treatment by drug courts, prisons, hospitals, and community sources. Interviews and surveys indicated that telehealth mitigated some treatment barriers caused by the pandemic.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers noted that the report focused primarily on positive study results, indicating improved retention in substance abuse treatment for California counties implementing American Society of Addiction Medicine (ASAM) criteria for treatment intake compared to counties that did not use this approach, with little attention to negative study results that were also important. The researchers pointed out that they did discuss the potential reasons for negative results, in particular that whether or not ASAM-based intakes were used did not affect retention when patients started outpatient treatment before moving to residential.
- Reviewers also felt that the researchers should discuss how this natural experiment study design could result in alternative explanations for their study results, for instance that counties that did not implement ASAM criteria were able to use larger residential centers with more patient beds than counties not implementing these criteria. The researchers reported that there were no differences in residential center capacity so this could not explain treatment retention differences between the two comparison groups of counties.
- The reviewers asked the researchers whether they omitted Los Angeles County treatment centers, which implemented a computerized ASAM-based intake process, from the main comparison of ASAM-based versus non-ASAM-based intake procedures because of the incomplete data researchers received from that county. The researchers confirmed that they had originally intended to omit the computerized procedures from the comparison and did not do so only as a result of the missing data. In the report, the researchers stated that the data from the computerized assessment were found to be unreliable.
- Similarly, the reviewers noted that the researchers described retention outcomes separately for patients in residential settings from patients who started in outpatient settings, but there was no reference to this differentiation in the study specific aims. The reviewers asked the researchers to clarify the results for the full sample as described in the study aims, rather than separately for these two groups based on treatment intensity. The researchers explained that since the study goal was to determine whether proper treatment placement would improve retention rates, it should be assumed that they would want to look at patients based on the level of care they received after the ASAM-based intake.