Alcoholism Treatment Matching: Methodological and Clinical Issues

1. Alcoholism Treatment Matching: Methodological and Clinical Issues Dennis M. Donovan, Ph.D. Alcohol & Drug Abuse Institute and Department of Psychiatry & Behavioral Sciences University of Washington CONJ 556:   Addiction: Mechanisms, Prevention, Treatment

2. The World's Largest 6-Pack:“Honestly, Officer, I only had one can….”

3. Treatment Brief Intervention Primary Prevention Spectrum of Intervention Response Thresholds for Action NoProblems Mild Problems Severe Problems Moderate Problems

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5. Selection of Level of Intensity of Intervention No Intervention Needed Brief Intervention Self-Help Groups Outpatient Treatment Intensive Day or Night Treatment Severity of Dependence Residential Treatment Miller, 1989

6. Institute of Medicine Report: Broadening the Base of Treatment for Alcohol Problems (1990) • It may no longer be appropriate to ask if treatment works, which is the best available treatment, or which treatment is more effective than another. • The question needs to be reframed: “Which kinds of individuals, with what kinds of alcohol problems, are likely to respond to what kind of treatments by achieving what kinds of goals when delivered by which kinds of practitioners?”

7. What Is Treatment Matching? “Deliberate and consistent attempt to select a specific candidate for a specific method of intervention in order to achieve specific goals.” Glaser & Skinner, 1982

8. The “Science” of Treatment Selection and Matching “I utilize the best from Freud, the best from Jung, and the best from my Uncle Marty, a very smart fellow.”

9. Key Conceptual and Methodological Issues in Patient-Treatment Matching Conceptual issues: • Selecting effective matching variables • Specifying the end result that matching is to enhance • Determining the stage(s) in the treatment process at which matching decisions are to be made Methodological issues deal with the type of patient-treatment match or interaction effect and include: • Nonlinear interaction effects • Higher-order interaction effects • Multilevel interaction effects Finney & Moos, 1986

10. Conditions Enhancing Probability of Identifying Interaction Effects Testing the Treatment Matching Hypothesis • Large clinical sample, allowing subject heterogeneity for meaningful subtypes • Controlled trial with random assignment to treatment conditions • Use of reliable and valid instruments to assess prognostic characteristics • Well-defined treatments that are clearly differentiable • Use of a multidimensional assessment approach • Inclusion of psychological variables (including degree of alcohol dependence) and demographic characteristics • Use of data analytic strategies that are appropriate for the detection of complex interactions while also controlling for prognostic indicators 1992

11. Methods of Treatment Matching • Client preference/self-selection • Client attribute by type of treatment (e.g., Project MATCH) • Identified problem by services provided (e.g., McLellan / ASI) • Severity of substance abuse problems / consequences by treatment intensity or setting (e.g., ASAM Criteria)

12. Degree of Empirical Evaluation Relative to Implementation of Matching Approaches High Client-Treatment Problem-Services Empirical Evaluation Severity- Setting Client Preference Low Low High Implementation

13. Methods of Treatment Matching: Client Preference/Self-Selection

14. Role of Client Choice in the Therapy Process • A common clinical process following assessment is that the client is advised of the “appropriate” form of therapy. • This is seen as undermining the client’s sense of responsibility with regard to the therapeutic process and may lead to dissatisfaction, reduced compliance and dropout. Van Audenhove & Vertommen, 2000

15. Role of Client Choice in the Therapy Process Treatment goals and approaches that have been chosen by the client, either independently or through negotiation with the clinician, are likely to capitalize on the client’s motivation and to increase compliance. Miller, 1989

16. “try to make me go to rehab, i won't go, no, no, no…!”

17. Does Self-Selection of Treatments Lead to Better Outcomes than Random Assignment? • Receiving treatment of preference had no measurable impact on treatment outcome, either for drinking behavior or general functioning. • Receiving treatment of preference had no measurable impact on treatment process, utilizing client-rated (satisfaction and effectiveness), clinician rated (rapport and engagement) and objective (number of sessions attended) measures. Adamson, Sellman, & Dore, 2005

18. Self-Directed Care • A system that is “intended to allow informed consumers to assess their own needs . . . determine how and by whom these needs should be met, and monitor the quality of services they receive” (Dougherty, 2003). • A system “in which funds that would ordinarily be paid to service provider agencies are transferred to consumers, using various formulas to account for direct, administrative, and other costs.” (Cook et al., 2004). SAMHSA, 2004

19. Patient-Centered Care • “Patient-centered care” is care that is “respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions.” • Patient access to and receipt of information that permits informed health care decisions • Supporting the client through disagreements about treatment decisions • Asking the patient’s goals for recovery • Factoring these into shared decision making for the recovery process • Assessing and supplementing education/information Source: Institute of Medicine (2006), Improving the Quality of Health Care for Mental and Substance-Use Conditions.

20. Methods of Treatment Matching: Client Attribute by Type of Treatment (e.g., Project MATCH)

21. Matching Alcoholism Treatment to Client Heterogeneity

22. Purpose of Project MATCH To determine if various types of alcoholics respond differentially to different treatment approaches

23. Why a Multi-Site Matching Trial? • There is considerable heterogeneity among alcoholics • No single treatment helps all alcoholics • Promising results in small-scale matching studies • Matching is a dominant question on the research agenda

24. Clinical Research UnitsProject MATCH Milwaukee Providence * Buffalo * Seattle VAMC * * * * WHaven VAMC * Albuquerque * Farmington * Charleston VAMC Houston VAMC

25. Two Parallel Study Arms To test the generalizability of matching in different client populations and treatment settings • Outpatient • Aftercare

26. Project MATCH Therapy Manuals To evaluate matching clients to distinct, manual-driven, theoretically-based treatments that are widely applicable to a range of settings and providers

27. Research Design: Outpatient Study

28. Assessment and Follow-up Protocol • Baseline Pre-Treatment • End of Treatment (Month 3) • Post-Treatment Follow-up: Mos 6, 9, 12, 15 • All contacts were in person except month 12 • Self reports corroborated by blood/urine samples and collateral reports

29. Gender Alcohol involvement Cognitive impairment Meaning seeking (spirituality) Motivation Sociopathy Social network support for drinking Alcohol dependence Level of anger Interpersonal dependency Prior AA involvement Self-efficacy Social functioning Antisocial personality disorder Type and severity of psychiatric disorder Religiosity Alcoholism type Readiness to change. Client Attributes Examined in Project MATCH

30. Outcome Variables Primary Measures • Percent of Days Abstinent (frequency) • Drinks per Drinking Day (intensity) Secondary Measures (Partial list) • Other measures of drinking • Negative consequences of drinking • Other substance use • Social functioning • Psychological functioning

31. Compliance in Project MATCH:Treatment AttendancePercent of Prescribed Sessions

32. The Crushing Weight of the Data

33. Mean Percent Days Abstinent as a Function of Time (Outpatient) Project MATCH Research Group, 1997

34. Proportion of Patients Maintaining Total Abstinence as a Function of Time (Outpatient)

35. Mean Drinks per Drinking Day as a Function of Time (Outpatient) Project MATCH Research Group, 1997

36. Proportion of Outpatients Avoiding a Heavy Drinking Day as a Function of Time Project MATCH Research Group, 1997

37. Alcohol Dependence: In the aftercare group, individuals with high levels of alcohol dependence benefited more from TSF than from CBT, whereas the reverse was true for patients low in dependence. Psychopathology: In the outpatient group, those without psychopathology were found to benefit more from TSF than from CBT. Anger: Also in the outpatient arm of the trial, patients high in anger had more successful outcomes with the MET than with the other two approaches. Social Network Support for Abstinence: Patients whose social networks offered less support for abstinence had better outcomes in TSF than in MET. Only 4 of 21Possible Treatment - Attribute Matches Found in Project MATCH

38. Project MATCH Findings • Treatment attendance was high across all three treatments • Excellent overall outcomes, with substantial reductions in frequency and intensity of drinking following treatment • Few differences among treatments • Outcomes similar for MET vs. CBT+TSF • Observed main effects generally favored TSF • Outcomes are not substantially improved by client-treatment matching.

39. “In sum, Project MATCH’s findings challenged the notion that patient-treatment matching is a prerequisite for optimal alcoholism treatment. Other than the four relationships, the findings did not show that matches between patient characteristics and treatments produced substantially better outcomes.” NIAAA's 10th Report to Congress

40. Was Project MATCH Right After All? Witkiewitz: J Abnorm Psychol, 116(2). 2007.378–394

41. Original Project MATCH Hypothesis: Individuals lower in baseline self-efficacy would have better outcomes if they were randomly assigned to CBT rather than to MET. Original Project MATCH Finding: No interaction effect obtained. Witkiewitz, et al., Finding: Provided support for the original self-efficacy matching hypotheses. Baseline self-efficacy was related to different outcomes depending on whether individual was randomly assigned to CBT or to MET, and this relationship was moderated by levels of drinking frequency. Interaction between self-efficacy and treatment assignment on percentage of drinking days for infrequent drinking class (top) and frequent drinking class (bottom) Witkiewitz: J Abnorm Psychol, 116(2). 2007.378–394

42. Subsequent Therapy Component by Client Attribute Interactions • A focus on emotional material in therapy was associated with more frequent alcohol consumption among patients high in depressive symptoms • Therapist use of confrontation was associated with more frequent alcohol consumption among patients at medium and high levels of trait anger while it was associated with less frequent alcohol consumption among patients low in anger • Confrontation was associated with more frequent alcohol consumption among patients high in interpersonal reactance (extent to which an individual generally resists being influenced by others) • Therapy structure was associated with more frequent alcohol consumption among patients at medium or high levels of reactance Karno & Longabaugh, Addiction, 102, 587–596, 2007

43. Effects of Match between Patient Depressive Symptoms and Therapy Emotion Focus PDA % Recovered Karno & Longabaugh, Addiction, 102, 587–596, 2007

44. Do Client Attribute / Treatment Matches Matter? • Mismatches between patient attributes and treatment appear to have serious consequences, and this effect is magnified with multiple mismatches. • Matches, on the other hand, while beneficial, may not be necessary to achieve good outcomes Karno & Longabaugh, Addiction, 102, 587–596, 2007

45. Still left with variable response….. • Even when treatment delivery is standardized and high adherence to manual is achieved, some patients do well and others do not. • Very hard to predict who will do well in a particular treatment • Nonresponse is often blamed on the patient, but that is likely not the whole story.

46. Another Possible Approach?Adaptive Treatment

47. In Adaptive Treatment Protocols… • One of the conceptual issues identified by Finney & Moos (1986): Determining the stage(s) in the treatment process at which matching decisions are to be made • Treatment is tailored or modified on the basis of measures of response (e.g., symptoms, status, or functioning) obtained at regular intervals during treatment • Goal is to deliver the least burdensome treatment that is effective, to promote better compliance over time • Rules for changing treatment are clearly operationalized and described….. “If……..Then”

48. Decision Rules If(tailoring variable) then(decision option) Example: If client does not complete web-based CBT assignments for 2 weeks Provide telephone Motivational Interviewing session

49. Operationalizing Clinical Decisions • Reduces inappropriate variance in treatment delivery • Provides framework for improving outcomes • Permits systematic research

50. An Example of an Adaptive Strategy for Aftercare for Patients Recently Treated for Substance Use Disorder (SUD) and Depression Goal: minimize relapse for all treated within constraints of health care system