No More Guesswork: Using Patient Outcomes Data to Construct Effective SUD Treatment Plans

December 27, 2017   Thomas G. Kimball, PhD

Recently we wrote about the use of outcomes data to identify the links between substance use disorder (SUD) and recovery by drawing comparisons between the current state of addiction treatment and the treatment of childhood cancer in the 1980s (see article).

The effectiveness and ineffectiveness of those treatments, and thus the advancement in medical science to save the lives of those children with cancer and people with a substance use disorder, could not be measured without the collection of data and the stories that data tells. Relying on longitudinal outcomes data, coupled with patient experience, is the best way to begin to eliminate the guesswork currently employed in most SUD treatment plans.

Medical Research vs. Industry Practice

If patients in the medical field were treated like customers in a consumer market it would give healthcare providers an incredible insight into patient needs. Marketers have an abundance of research on demographics and consumer behavior that can tell them exactly the following:

  • What a customer wants
  • What time of year customers buy
  • What customers buy based off their income
  • Where customers live
  • Socioeconomic information such as customer level of education, family background, income data, etc.

This information is so comprehensive for professionals in the consumer market that some companies have started using artificial intelligence to predict nearly to the day when a person will make a particular purchase. This kind of confidence is light years ahead of how we handle our consumers, or patients, in the healthcare field. There is little attention paid to the demographics of patients and their needs. This is slowly changing; however, there is still a disconnect between the research utilized in measuring effective treatments and the actual practice of collecting the data on those treatments.

The easiest way to discover and implement the most effective treatments is to look at the best practices collected by research institutions. Across the board, we’re finding that there isn’t a single effective method for treatment. Instead, effective treatment is found in a multi-modal approach that combines several effective treatments into a patient-centered approach. Of course, those effective treatments are identified through the collection of outcomes data from research institutions that are then put into practice by healthcare providers.

Take, for instance, the Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the Department of Health and Human Services whose mission is to reduce the impact of substance abuse and mental illness on America's communities. They research and report on evidence-based practices proven effective in the treatment of substance use.

Consider also the National Institutes of Health (NIH) whose research in substance use disorders has found that there isn’t a singular method of treatment that’s more effective than another. Instead, it’s better to have a comprehensive treatment method with a multi-modal approach. Through their research they have developed guidelines and principles for best practices that can be utilized together to treat an individual, including:

  • Community reinforcement
  • 12-step groups
  • Cognitive therapy (CT)
  • Cognitive behavioral therapy (CBT)
  • Therapy-based treatment
  • Pharma-based treatment
  • Community reinforcement approaches
  • Vouchers
  • Motivational enhancement therapy
  • Matrix Model
  • Family behavioral therapy

The volume of different therapies is immense and collecting data to determine the most effective is a herculean endeavor.

An Individualized, Evidence-based Approach

Patient assessment is key to determining the best treatment methods. If you look at the number of treatment modalities available, it can be difficult to determine which is most effective for each individual patient. This is especially true with substance use disorders which often co-occur with a broad range of other mental health problems. In order to treat an individual, it’s important to understand that effective treatment must also consider and address other medical maladies, including:

  • Mental health
  • Nutrition / Diet
  • Exercise regimen
  • Physical health
  • Family medical history and other aspects of a patient’s health

For instance, we know that a patient with substance use disorder with a co-occurring disorder will not react to treatment in the same way a patient without a co-occurring disorder will. Any mental health issue on top of their substance abuse issue will dramatically change their treatment needs including the need for an integrated approach. Using the research from SAMHSA and NIH it’s possible to put together an individualized care plan. There is a myriad of criteria that is considered when putting together a plan:

  • Co-occurring disorder or presence of other outside conditions from SUD found during an assessment will require a different treatment plan (mental disorder, PTSD, criminal activity, etc)
  • Introducing Medication-Assisted Treatment into the picture
  • Disease severity
  • Level of Care (Inpatient, Outpatient, etc)
  • Presence of Chronic Pain
  • Modalities of therapy that might be needed or helpful (music, equine, mindfulness)
  • Tolerance of a patient towards different modalities throughout the course of their treatment

If you go back to the marketing metaphor, a key question when considering your clients’ needs is: what does the client want?

This simple question is complicated when applied to a healthcare scenario. The issue we face is providers have a difficult time knowing when a patient reaches their threshold and when they are just avoiding necessary treatment.

Consider a patient with cancer versus a patient with a substance use disorder:

If a patient with cancer is told that chemotherapy is a necessary treatment and it would need to be administered for six weeks to be effective it is more unlikely that the patient would protest at this treatment regimen. However, if a patient with substance use disorder was told to adhere to a specific recovery program there is a greater likelihood of pushback, refusal, or non-compliance because of a lack of consistent data.

Looking for Cues to Diagnose and Treat SUD

The Cancer Research Comparison

Biological markers have long been used to detect cancer. If we could find similar biological markers to detect substance use disorders, it would advance our understanding of the disease’s origins and how it transforms over time immensely. It’s likely that if we found such markers, the regime for a patient in recovery would become as stringent as one with cancer.

Luckily, the field of addiction recovery is advancing to a similar level of detection, treatment, and monitoring. If we determine a biological marker for SUD, and in so doing find markers that indicate levels of recovery, then we could get a better sense of when someone needs an adjustment in treatment modalities.

Functional Near-Infrared Spectroscopy (fNIR) is an emerging technology that could deliver these types of markers. fNIR is a method of detection that can identify addiction-cue reactivity in the brain and tell us whether a patient with addiction is triggered by their addiction after they’ve begun recovery.

Another cue that can be taken from cancer treatment is the way in which course-correction is approached when treatments are ineffective. It’s easy, as a society, for us to accept that if a cancer treatment is not working then there must be a pivot to another method. Radiation therapy isn’t working? Let’s switch to chemotherapy, or surgery, or both.

This is generally accepted as necessary in the treatment of cancer. When treating substance use disorders, it’s not as cut and dry, and it’s difficult to convince a patient whose treatment isn’t working of the value of a different or complementary treatment method.

Treatments do change, and treatment plan reviews occur every so often with patients in order to determine if there should be a change in the course of action. However, these changes are usually based on clinical judgment or informed opinions, and not data driven. Whereas, in most cancer treatment there is an excess of clinical data to base a move to alternative treatment methods.

Monitoring Stress to Accompany SUD Treatment

Treatment plans can be developed for each individual, but there isn’t a guarantee that they’ll work just because the data says they should. There are a number of factors that can complicate treatment, especially for those with a substance use disorder. Stress, for one, is an enemy for people in recovery. The more stress that people are experiencing, both real and perceived, the higher the probability that an individual may relapse.

For example, we’ve seen people relapse when a significant event takes place, especially with a traumatic event like a death. People may become very, very vulnerable in that moment. But the vulnerability doesn’t have to come from a negative event. It could simply be that something distinct happens.

A college graduation, by the individual in recovery or someone close to them, would be a good example of a distinct event. In that moment of celebration, a person can become very vulnerable to a use event due to a variety of external and internal factors.

There are a range of different modalities that people in recovery utilize in order to monitor and reduce stress levels. There are also companies that are innovating new and exciting ways to incorporate wearable stress monitors and mobile devices into our everyday lives. MAP has created a partnership with LIEF to test the efficacy of these types of devices with a portion of our post-treatment patient population. Though LIEF’s wearable technology wasn’t necessarily designed solely for medical treatment applications, the combination of a stress reduction technology with post-treatment recovery modalities has incredible potential.

No More Guesswork for SUD

Currently, it’s incredibly difficult to accurately predict what could lead to a relapse and when. Unless comprehensive data is taken into account, and patients are treated with the same sort of severity and seriousness as other healthcare consumers with fatal diseases, like cancer patients, we will continue to be mired in what amounts to a homogenized set of treatment plans that are unpredictable in terms of outcomes.

We can start to eliminate the guesswork that goes into diagnosing and treating SUD once and for all. Our industry must make more considerable strides toward incorporating comprehensive outcomes data, patient experience, and emerging technologies into crafting treatment plans.

Granted, this is not an easy challenge to take on, but it is one that is so necessary in our country. The need for a shift in approach is evidenced by the increasing amount of coverage that the Opioid Crisis has received in the last year. Unfortunately, that is only part of the larger Addiction Epidemic that Americans have faced for the past several decades or more.

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