Case mangement for persons with substance use disorders.

Hesse M, Vanderplasschen W, Rapp R, Broekaert E, Fridell M

Published Online:

October 5, 2011

Illicit use of drugs such as opioids, cocaine, amphetamines, cannabis and alcohol dependence have health, social and economic complications. Users often have long-term problems in addition to substance abuse. Case management is a client-centred strategy involving assessment, planning, linking to relevant services and community resources and advocacy. Its intent is to improve the co-ordination and continuity of delivery of services. Brokerage case management sets out to help clients identify their needs and broker services in one or two contacts; intensive case management involves a closer interaction between case manager and client; assertive community treatment (provides assertive outreach and direct counselling services; strengths-based case management focuses on self-direction and the use of informal networks rather than agency resources by applying active outreach.
From this review, case management effectively linked people with substance abuse to community and treatment services as compared to treatment as usual or other viable treatment options, such as psycho-education or brief interventions. This conclusion is based on 10 randomised controlled trials involving 3132 participants that compared case management to usual treatment. Two studies compared case management with other specific treatments. Additional analysis of the studies suggested that the use of a manual to guide the delivery of case management could increase linkage. A total of 15 controlled studies that randomised a total of 6694 participants were included in the review. One study was conducted in Europe; all other studies were from North America.
Seven studies with 2391 participants did not find a clear reduction in illicit drug use with case management compared with usual treatment; similarly with alcohol use (two studies). A single, large trial showed that case management for heroin users was superior to psycho-education and drug counselling in reducing drug use. The extent of linkage varied significantly between studies, which is likely to be influenced by the availability of services in the community, the model of case management, how effectively it is applied and its integration in the local network of services.

Abstract (click to read)

Background:

Patients with alcohol and other drug use disorders (AOD) frequently have multiple social, physical, and mental health treatment needs, yet have difficulty accessing community services, including drug abuse treatment. One strategy for linking patients with AOD with relevant services is case management, where a single case manager is responsible for linking patients with multiple relevant services.

Objectives:

To conduct a systematic review of all RCTs on the use of case management for helping drug abusers in or out of treatment. Outcome criteria included successful linkage with other services, illicit drug use outcomes, and a range of related outcomes.

Search strategy:

We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2006), MEDLINE (1966 - 2006), EMBASE (1980 - 2006), LILACS (1982 - 2006), PsycINFO (1973 - 2006), Biological Abstracts (1982 t- 2000). Reference searching; personal communication; conference abstracts; book chapters on case management.

Selection criteria:

Randomized controlled studies that compared a specific model of case management with either treatment as usual or another treatment model, included only patients with at least one alcohol or drug related problem.

Data collection and analysis:

Two groups of reviewers extracted the data independently . Standardized mean difference was estimated.

Main results:

In total, we could extract results from 15 studies. Outcome on illicit drug use was reported from 7 studies with 2391 patients. The effect size for illicit drug use was not significant, and small (standardized mean difference (SMD)=0.12, confidence interval=-0.09,0.29, p=0.20). Substantial heterogeneity was found (I2=69.9%). Linkage to other treatment services was reported in 10 studies with 3132 patients. The effect size for linkage was moderate (SMD=0.42, 95% confidence interval=0.21 to 0.62, p<0.001), but substantial heterogeneity was found (I2=85.2%). Moderator analyses suggested that a part of the heterogeneity found in linkage studies could be explained by the presence or absence of a treatment manual for case management. A single, large trial of case management with two arms, showed that case management was superior to psycho education and drug counselling in reducing drug use.

Authors' conclusions:

There is current evidence supporting that case management can enhance linkage with other services. However, evidence that case management reduces drug use or produce other beneficial outcome is not conclusive.

This record should be cited as:

Hesse M, Vanderplasschen W, Rapp R, Broekaert E, Fridell M. Case management for persons with substance use disorders. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006265. DOI: 10.1002/14651858.CD006265.pub2

Assessed as up to date:

August 7, 2007

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Primary Review Group:

Drugs and Alcohol Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

Is case management helpful for people with substance abuse disorders?

Bottom line:

Compared with treatment as usual or other variable treatment options, such as psycho-education or brief interventions, case management can enhance linkage with other community and treatment services. The use of a manual to guide the delivery of case management seemed to increase linkage.

Caveat:

The extent of linkage varied significantly between studies. There was no conclusive evidence that case management improved other outcomes, such as reducing drug use. One study was conducted in Europe; the other studies were conducted in North America.

Context:

Case management is a client-centred strategy involving assessment, planning, linking to relevant services and community resources, and advocacy. The intent is to improve the coordination and continuity of delivery of services.

Cochrane Systematic Review:

Hesse M et al. Case management for persons with substance abuse disorders. Cochrane Reviews 2007, Issue 4. Art No : CD006265 .DOI : 10.1002/14651858. CD006265.pub 2. The review contains 15 studies involving 2,391 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Tobacco, drugs, & alcohol dependence > Polydrug use

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Case mangement for persons with substance use disorders.

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