Choosing the OptimumTreatment 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?

AcknowledgmentsResearch Collaborators

Neil B. McGillicuddy, Ph.D.

Robert B. Whitney, M.D.

Gerard J. Connors, Ph.D.

George D. Papandonatos, Ph.D.

Clinical Coordinator

Joan Duquette

Research Staff

Carrie Pengelly

Jean Finn

Dennis Dickman

Kathy Skibicki

Sue Sperrazza

Rebecca Eliseo-Arras

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.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1990 2002

Inpatient/Residentialprograms

Outpatient programs

Source: McLelland (2006)

The Practical Effect onPrograms Available

Pe

rce

nta

ge o

f D

ays

Ab

stin

en

t

Month

Inpatient

Outpatient

Finney & Moos (1996)

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)

0

5

10

15

20

25

Inpatient Intenstive Outpatient Standard Outpatient

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nta

ge

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 RIAClinical Research Center

ECMC Inpatient & OutpatientChemical 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

Aftercare Sessions (6 months)24 24

Sample CharacteristicsInpatient(N = 84)

Outpatient(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(N = 84)

Outpatient(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 BaselineDrinking-Related Measures

Inpatient(N = 84)

Outpatient(N = 92)

M M

% Voluntary alcohol abstinent days/mo. 31.55 27.49

% Voluntary alcohol/drug abstinent days/mo.

22.35 22.02

% Totally abstinent from alcohol/mo. 8.01 4.27

Drinks per drinking day 13.39 14.36

% Hospitalized/Incarcerated at least 1 day/mo.

13.98 11.50

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

7.4

7.5

7.6

7.7

7.8

7.9

8

8.1

8.2

8.3

8.4

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 SubsequentHospital Admission, IP Treatment, or Incarceration

Point Prevalence of a SubsequentHospital Admission, IP Treatment, or Incarceration

Point Prevalence of a SubsequentHospital Admission, IP Treatment, or Incarceration

Point Prevalence of a SubsequentHospital 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 inpatientis what they need, seriously consider giving it to them!

Thank You!