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Improving SUD Continuity Improving SUD Continuity of Care: of Care:
Bringing Science to PracticeBringing Science to Practice
Steven J. Lash, Ph.D. Associate Professor of Psychiatry and Neurobehavioral Science,
Salem VAMC & University of Virginia
Preparation of this presentation was supported in part by grants from the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (99-282-2 & 03-267-3). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
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Clinical Trial of Clinical Trial of Contracting Prompting Contracting Prompting and Reinforcing (CPR) and Reinforcing (CPR) Aftercare Attendance.Aftercare Attendance.
Need for Continuing Care Adherence in SUD (Substance Use Disorder) Treatment
CPR is a clinic-friendly approach for promoting CPR is a clinic-friendly approach for promoting SUD Continuing Care Adherence.SUD Continuing Care Adherence.
Hypothesized that CPR would produce greater continuing care adherence and treatment outcome than STX.
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.
Clinical trial at the Salem VAMC comparing
CPR to Standard Treatment (STX).
Compare CPR vs. STX on Continuing Care Compare CPR vs. STX on Continuing Care Attendance & Treatment Outcome.Attendance & Treatment Outcome.
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Why is Adherence to SUD Why is Adherence to SUD Continuing Care Critical?Continuing Care Critical? Most Treatment Programs are 1 month Most Treatment Programs are 1 month
or less or less followed by a recommendation of followed by a recommendation of outpatient aftercare therapy and AA/NA..outpatient aftercare therapy and AA/NA..
Danger Period for Relapse:Danger Period for Relapse: Two-thirds of Two-thirds of relapses occur within the first 3 months of relapses occur within the first 3 months of beginning treatment (Marlatt, 1985).beginning treatment (Marlatt, 1985).
Few Patients Follow-ThroughFew Patients Follow-Through with with continuing care recommendations.continuing care recommendations.
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VAMC Aftercare RatesVAMC Aftercare Rates
Only 54% of VA patients attend 1 or Only 54% of VA patients attend 1 or more aftercare sessions (Fortney et al., more aftercare sessions (Fortney et al., 1995).1995).
Only 20% of VA patients attend 2 or Only 20% of VA patients attend 2 or more aftercare sessions in the first month more aftercare sessions in the first month of aftercare (Peterson et al., 1994).of aftercare (Peterson et al., 1994).
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Minimum Effective Dose of Minimum Effective Dose of SUD Treatment?SUD Treatment?
Treatment of less than 3 months is typically Treatment of less than 3 months is typically ineffective (Ersoff et al., 1996; Simpson et ineffective (Ersoff et al., 1996; Simpson et al., 1997 & 1999).al., 1997 & 1999).
Treatment is most effective when at least 7 Treatment is most effective when at least 7 to 12 months are received (Moos et al., to 12 months are received (Moos et al., 1999; Ritscher et al., 2002).1999; Ritscher et al., 2002).
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% ABSTINENT at 1 YEAR
34 34
43
65
0
10
20
30
40
50
60
70
What Does Aftercare What Does Aftercare Add?Add?
0 Months 1-3 Months 4-6 Months 7+ Months
Months in Aftercare *source:Moos, Finney, Ouimette, & Suchinsky, 1999.
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What Does AA or NA What Does AA or NA Add?Add?
None 1-9 Meetings
Number of AA/NA Meetings *source:Moos, Finney, Ouimette, & Suchinsky, 1999.
% ABSTINENT FOR 1 YEAR
29 31
52
67
0
10
20
30
40
50
60
70
80
10-29 Meetings30+AA/NA
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Cause and Effect?Cause and Effect?
Interventions that increase the duration of Interventions that increase the duration of treatment typically show improved treatment typically show improved treatment outcome compared to standard treatment outcome compared to standard care.care.
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Research Questions?Research Questions?
Can we increase continuing Can we increase continuing care adherence using clinic- care adherence using clinic- friendly strategies?friendly strategies?
Does increased continuing Does increased continuing care adherence result in care adherence result in improved treatment outcome?improved treatment outcome?
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The CPR InterventionThe CPR Intervention
CContracting + ontracting + PPrompting + rompting + RReinforcing einforcing SUD continuing care attendanceSUD continuing care attendance
Goal = Keep patients in treatment for at Goal = Keep patients in treatment for at least 3 months, the minimum amount of least 3 months, the minimum amount of time associated with positive treatment time associated with positive treatment outcome.outcome.
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Contracting, Prompting Contracting, Prompting and Reinforcing and Reinforcing Continuing Care Continuing Care
Attendance Attendance (CPR)(CPR) MotivationalMotivational ContractContract providing abstinence providing abstinence
rates associated with continuing care rates associated with continuing care participation.participation.
PromptsPrompts for attendance with feedback on for attendance with feedback on progress toward reinforcers/goals.progress toward reinforcers/goals.
Social Social ReinforcementReinforcement of aftercare attendance.of aftercare attendance.
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CPRCPR:: ContractingContracting
Conducted during individual therapy prior to Conducted during individual therapy prior to completion of initial intensive treatment.completion of initial intensive treatment.
Brief- 20 minutes, or less.Brief- 20 minutes, or less.
First contract for first 3 months of group and First contract for first 3 months of group and individual therapy, and AA or NA.individual therapy, and AA or NA.
Second contract for remainder of 1 year.Second contract for remainder of 1 year.
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Welcome letter prior to first aftercare session.Welcome letter prior to first aftercare session.
Automated phone reminder prior to all Automated phone reminder prior to all appointments.appointments.
Phone call and letter from therapist for missed Phone call and letter from therapist for missed appointments.appointments.
Appointment cards prior to all appointments, Appointment cards prior to all appointments, containing feedback on progress toward next containing feedback on progress toward next reinforcer.reinforcer.
CPR:CPR: PromptingPrompting
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Appointment Card Appointment Card PromptPrompt
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90-Days of Treatment Certificate90-Days of Treatment Certificate- 28 days - 28 days residential program plus at least 6 out of 9 weeks of residential program plus at least 6 out of 9 weeks of aftercare group therapy and 2 monthly individual aftercare group therapy and 2 monthly individual therapy sessions.therapy sessions.
4 Months of Treatment Medallion4 Months of Treatment Medallion- above plus 2 - above plus 2 group sessions and 1 individual therapy session in group sessions and 1 individual therapy session in month 4.month 4.
1 Year of Treatment Certificate and Medallion1 Year of Treatment Certificate and Medallion for completing 1 Year of treatment- the above plus for completing 1 Year of treatment- the above plus 8 months of aftercare (monthly individual therapy 8 months of aftercare (monthly individual therapy and twice monthly group therapy).and twice monthly group therapy).
CPR:CPR: Social Social ReinforcementReinforcement
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90 DAYS90 DAYSJohn Doe
is hereby awarded this certificate for successful completion of his
90
-
day commitment to the Salem VAMC’s
Substance Abuse Treatment Program.
In addition to completing the 28
-
day program,
you have attended at least 7 group meetings
and 2 individual aftercare sessions over 9 weeks.
YOU HAVE GONE A STEP FARTHER AND
WALKED THE WALK.
__________________
August 2, 2003 Janet McElligott
,
LCSW
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““Improving Substance Improving Substance Abuse Treatment Abuse Treatment
Aftercare Adherence and Aftercare Adherence and Outcome”Outcome”
Lash, Stephens, Burden, Grambow, DeMarce, Lash, Stephens, Burden, Grambow, DeMarce, Jones, Lozano, Jeffreys, Fearer, & Horner (in Jones, Lozano, Jeffreys, Fearer, & Horner (in
press). press). Psychology of Addictive BehaviorsPsychology of Addictive Behaviors
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ParticipantsParticipants 150150 graduates of the Salem VA SARRTP graduates of the Salem VA SARRTP
(VA averages in parentheses; Moos et al., 1999).(VA averages in parentheses; Moos et al., 1999).
Mean age was 48.6 years (43 years).Mean age was 48.6 years (43 years).
97% (99%) Male.97% (99%) Male.
45% (46%) Caucasian, 53% (49%) African-American, 45% (46%) Caucasian, 53% (49%) African-American,
1% (5%) Other racial groups. 1% (5%) Other racial groups.
13% (19%) Married, 65% (56%) Separated or divorced, 13% (19%) Married, 65% (56%) Separated or divorced,
20% (23%) Single, 3% (2%) Widowed.20% (23%) Single, 3% (2%) Widowed.
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Design & HypothesesDesign & Hypotheses Clinical trial at the Salem VA SARRTP. 150 participants Clinical trial at the Salem VA SARRTP. 150 participants
blocked on SUD diagnosis and randomly assigned to CPR or blocked on SUD diagnosis and randomly assigned to CPR or STX. STX has routine clinical contract, prompts, and STX. STX has routine clinical contract, prompts, and reinforcement.reinforcement.
Hypothesized that CPR would produce greater adherence to Hypothesized that CPR would produce greater adherence to continuing care and improved treatment outcome than STX.continuing care and improved treatment outcome than STX.
Assessed at baseline, 3-, 6- and 12-month follow-up Assessed at baseline, 3-, 6- and 12-month follow-up interviews using Form-90, biochemical substance use screens, interviews using Form-90, biochemical substance use screens, collateral report, & medical records.collateral report, & medical records.
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ASI Problem Index ASI Problem Index ScoresScores
00.10.20.30.40.50.60.70.8
National Sample Our Sample
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Participant DiagnosesParticipant Diagnoses
0%10%20%30%40%50%60%70%80%
National Sample Our Sample
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Follow-up RatesFollow-up Rates
0%10%20%30%40%50%60%70%80%90%
100%
3 Months
6 Months**
12 months
STXCPR
**p= .04
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The Impact of CPR on The Impact of CPR on Treatment Adherence Treatment Adherence
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Began Aftercare?Began Aftercare?
82.7 94.7
0
10
20
30
40
50
60
70
80
90
100
Perc
enta
ge o
f Vet
eran
s Who
Be
gan
Afte
rcar
e
STX CPR p = .020
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SUD Continuity of Care Goal SUD Continuity of Care Goal in the VA Systemin the VA System
Retain VA patients treated for SUDs for at least 2 Retain VA patients treated for SUDs for at least 2 sessions each month for at least 3 months.sessions each month for at least 3 months.
Goal is to have at least 32% of each VA’s Goal is to have at least 32% of each VA’s patients meet this performance standard.patients meet this performance standard.
Average VA score: 27% (FY 2004 2Average VA score: 27% (FY 2004 2ndnd Quarter). Quarter).
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36% 55%
0%
10%
20%
30%
40%
50%
60%
% o
f Vet
eran
s Mee
ting
the S
UD
CO
C
Perf
orm
ance
Mea
sure
STX CPR p = .022
SUD Continuity of Care SUD Continuity of Care Performance MeasurePerformance Measure
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SUD Continuity of Care SUD Continuity of Care Performance MeasurePerformance Measure
27% 36% 55%
0%
10%
20%
30%
40%
50%
60%
% o
f Vet
eran
s Mee
ting
the
SUD
CO
C
Perf
orm
ance
Mea
sure
National Average STX CPR
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Monthly Aftercare AttendanceMonthly Aftercare Attendance(at least 2 sessions/month)(at least 2 sessions/month)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2 3 4 5 6 7 8 9 10 11 12
STXCPR
p < .023Months
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Survival Analysis- Time in Survival Analysis- Time in TreatmentTreatment
4.4 5.5
0
1
2
3
4
5
6
Mea
n M
onth
s in
Tre
atm
ent
Pri
or t
o D
isch
arge
STX CPR
p < ..02
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The Impact of CPR on The Impact of CPR on Support Group Adherence Support Group Adherence
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Began AA or NA?Began AA or NA?
74.1 77.8
0
10
20
30
40
50
60
70
80
90
100
Perc
enta
ge o
f Vet
eran
s Who
Be
gan
Afte
rcar
e
STX CPR p = .65
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Number of Days of AA or NA Number of Days of AA or NA MeetingsMeetings
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Baseline 3 Months 6 Months 1 Year
STXCPR
p = .74 p = .27p = .19p = .02
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The Impact of CPR The Impact of CPR on on
Treatment Treatment OutcomeOutcome
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Abstinence at 12 MonthsAbstinence at 12 Months
35.5 55.7
0
10
20
30
40
50
60
% o
f Vet
eran
s Abs
tinen
t (d
urin
g th
e la
st 3
Mon
ths)
at t
he 1
2-m
onth
Fol
low
-up
Inte
rvie
w
STX CPRp = .03
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1) Treatment condition (CPR vs. STX) has 1) Treatment condition (CPR vs. STX) has an effect on outcome. an effect on outcome.
2) CPR affects the attendance.2) CPR affects the attendance.
3) Attendance related to Abstinence.3) Attendance related to Abstinence.
4)4) Controlling for attendance, the effect of Controlling for attendance, the effect of CPR on abstinence is reduced.CPR on abstinence is reduced.
Does Attendance Mediate Does Attendance Mediate Outcome?Outcome?
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% of Days Using Substances % of Days Using Substances
0%
5%
10%
15%
20%
25%
3 Months 6 Months 12 Months
STXCPR
p= .41 p= .72 p=.29
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Summary of ResultsSummary of Results CPR increases continuing care adherence CPR increases continuing care adherence
compared to STX.compared to STX.
15% increase in initiation of aftercare.15% increase in initiation of aftercare.
53% increase in the SUD COC performance 53% increase in the SUD COC performance measure.measure.
33% increase in time in treatment33% increase in time in treatment
XX Did Not Increase AA/NA attendance. Did Not Increase AA/NA attendance.
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CPR improves abstinence rates at 1 yearCPR improves abstinence rates at 1 year
compared to standard care.compared to standard care.57% increase in abstinence rates at 1 year in 57% increase in abstinence rates at 1 year in
preliminary findings. preliminary findings.
XX No decrease in the percentage of days using No decrease in the percentage of days using substances at 12 monthssubstances at 12 months
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Highlights Highlights Clinic-friendly intervention increases Clinic-friendly intervention increases
treatment adherence, including performance treatment adherence, including performance on the SUD COC performance measure.on the SUD COC performance measure.
CPR results in increased abstinence rates at 1 CPR results in increased abstinence rates at 1 year follow-up.year follow-up.
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Our PlansOur Plans Training in VISN 6. Training in VISN 6. Downloadable materials posted on a VA Downloadable materials posted on a VA
website (http:vaww.mentalhealth.med.va.gov/).website (http:vaww.mentalhealth.med.va.gov/). Automate attendance tracking, prompting, and Automate attendance tracking, prompting, and
therapist materials.therapist materials. Make reinforcers more potent, frequent, and Make reinforcers more potent, frequent, and
immediate.immediate. Outpatient Trial- does this work with intensiveOutpatient Trial- does this work with intensive
outpatient treatment?outpatient treatment? Multi-site Trial.Multi-site Trial.
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