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Author List:
Humphreys K (VA CHCE)
Trafton JA (VA CHCE)
Oliva EM (University of Minnesota)
Objectives:
Adherence to clinical practice guidelines for heroin dependence treatment significantly enhances outcomes in controlled clinical trials with standardized treatments and selected patient samples, but many clinicians remain skeptical as to whether such results are relevant to everyday practice. Accordingly, the Multisite Opiate Substitution Treatment (MOST) study evaluated whether practice guideline concordance improves treatment effectiveness in real-world methadone clinics treating typical VA patients.
Methods:
A quasi-experimental, longitudinal design was employed. Two groups of clinics were identified that were relatively adherent (n=4 clinics) or non-adherent (n=4) to clinical practice guidelines concerning methadone dose levels and psychosocial service provision. Veterans (n=267) entering these clinics were interviewed at baseline by research staff and then followed-up six months later (91% follow-up rate). To represent real-world practice conditions, clinics provided care in accordance with their usual approach and no patient exclusion criteria were employed. Primary measures were the SF-36V, urinalysis results, and scales from the Addiction Severity Index (ASI).
Results:
Patients at guideline concordant clinics and guideline discordant clinics did not differ at treatment intake on race, gender, age, education, employment, mental health functioning or drug problem severity. However, by six month follow-up, repeated measures analysis of variance indicated that clean urine tests, self-reported days without heroin use, and mental health functioning all increased significantly more (p <.01) in guideline concordant than in discordant clinics. Most notably, days of heroin use per month at follow-up were almost twice as high in guideline discordant clinics (5.0 days vs. 2.7 days, F=9.11, p = .003).
Implications:
Even though real-world practice may not be able to follow guidelines as closely as do manual-guided, monitored providers in clinical trials, and even though real-world patients may be more troubled than selected samples in clinical trials, following practice guidelines still leads to more effective care for heroin dependent veterans in the real world.
Impacts:
Everyday practice is far “messier” than randomized clinical trials, yet RCT-derived practice guidelines can still help front-line clinicians make significant improvements in the health of their addicted patients.
