Researchers from California have found that the linkage intervention (LINKAGE), the first intervention to engage patients receiving addiction treatment with health care using the electronic health record (EHR), shows feasibility and effectiveness in helping patients engage in their health care and increase communication with their physicians.
“To our knowledge, the linkage intervention is the first trial of an intervention focused on increasing engagement of patients having alcohol and other drug (AOD) disorders with health care using the EHR and patient portals as a platform, as well as a patient activation approach used for other health conditions for engaging patients,” wrote Constance M. Weisner, DrPH, LCSW, from the Department of Psychiatry at the University of California in San Francisco and colleagues.
In the United States, 3.9% of the adult population met diagnostic criteria for drug use disorders in 2013, and 13.9% met criteria for alcohol use disorders. More than 3 million US adults enter treatment for addiction every year, and this number will increase with its new status as an essential benefit of patient care.
“Patients with AOD use disorders have high rates of medical and psychiatric comorbidities and complex treatment needs,” the authors wrote. “They often rely on emergency services, seldom using preventive services even when they have health insurance, with that trend increasing in recent years… Although a robust linkage between mainstream health care and addiction treatment would benefit these patients, this goal has not been accomplished.”
The researchers conducted a nonrandomized clinical trial of 503 participants at the San Francisco outpatient addiction treatment clinic of Kaiser Permanente Northern California to compare the LINKAGE intervention with usual care (UC). Intervention allocation was determined by a nonrandomized, alternating off-and-on design over 30 months (ie, 5 alternating 3-month periods for each condition). After a random start, the LINKAGE intervention groups alternated with the UC medical education groups every 3 months.
Participants in both usual care and the LINKAGE intervention received standard treatment of medical examinations, detoxification, and a 2 week stabilization program. Participants then either received usual care or LINKAGE medical education sessions in the next study phase, which lasted for 6 weeks and consisted of 2 groups per day 5 days a week.
Usual care sessions were 45 minutes with a licensed therapist focusing on medical and psychological problems. LINKAGE participants received 6, 45-minute sessions with a clinical psychologist which focused on demonstrating how health care is related to overall health, and during which they learned key patient skills and practiced skills necessary for collaborative communication with health care professionals.
Both groups participated in therapy groups, individual counseling, 12-step meetings, and weekly breathalyzer and urine screens.
The researchers found that LINKAGE participants had more days of patient portal log-in, during which they sought medical advice, received messages from primary care physicians, checked on laboratory test results, and reviewed medical information. Participants with psychiatric comorbidity had findings similar to those of the full sample, indicating that the intervention was also beneficial in engaging these patients.
While abstinence rates were high in both groups (≥70% for both), and depression outcomes significantly improved for both groups, LINKAGE did not result in better 6 month AOD or depression outcomes. The researchers noted that LINKAGE did not focus on either of these outcomes, however.
“Six months may not have been long enough to observe any differences in these outcomes given the intensive treatment program. However, by taking better care of their health, we expect that LINKAGE participants will have better outcomes than UC participants over time,” the authors wrote. “Because AOD disorders are chronic health conditions requiring ongoing care, we also expect that, by engaging patients in their health care, potential service needs will be identified earlier and relapse avoided.”
Summary & Clinical Applicability
More than 3 million US adults enter treatment for addiction every year, a number that will increase with its new status as an essential benefit of patient care. These patients often have co-occurring problems, and need their care to be integrated with mainstream healthcare. While the LINKAGE intervention did not achieve short term differences in depression or in alcohol and other drug use disorders, it will be important to understand if it benefits patients in avoiding relapse and in improving overall health.
Limitations & Disclosures
The study did not use a randomized design: it used an off-and-on, non-randomized clinical trial design, in which patient allocation was done by alternation, with different cohorts changing every 3 months over 30 months. Randomization would have resulted in contamination between study conditions because patients in both conditions were together during other parts of the standard program.
The study may have been underpowered for examining the effect on patient activation level. Because follow-up interviews were conducted by phone, it did not include validation with biological specimens. However, self-reported differences should have been similar for both conditions, and other studies have found high concurrence.
This study was supported by National Institutes of Health Center Grant P50 DA009253 from the National Institute on Drug Abuse.
Clinicaltrials.gov Identifier: NCT01621711
Weisner CM, Chi FW, Lu Y, et al. Examination of the Effects of an Intervention Aiming to Link Patients Receiving Addiction Treatment With Health Care. The LINKAGE Clinical Trial. JAMA Psych. 2016; doi:10.1001/jamapsychiatry.2016.0970.