1 Improving SUD Continuity of Care: Bringing 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 ( & ). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

2 Clinical Trial of Contracting Prompting and Reinforcing (CPR) Aftercare Attendance. Need for Continuing Care Adherence in SUD (Substance Use Disorder) Treatment CPR is a clinic-friendly approach for promoting SUD Continuing Care Adherence. CPR is a clinic-friendly approach for promoting SUD Continuing Care Adherence. Hypothesized that CPR would produce greater continuing care adherence and treatment outcome than STX.

3. Clinical trial at the Salem VAMC comparing CPR to Standard Treatment (STX). Compare CPR vs. STX on Continuing Care Attendance & Treatment Outcome. Compare CPR vs. STX on Continuing Care Attendance & Treatment Outcome.

4 Why is Adherence to SUD Continuing Care Critical? Most Treatment Programs are 1 month or less followed by a recommendation of outpatient aftercare therapy and AA/NA.. Most Treatment Programs are 1 month or less followed by a recommendation of outpatient aftercare therapy and AA/NA.. Danger Period for Relapse: Two-thirds of relapses occur within the first 3 months of beginning treatment (Marlatt, 1985). Danger Period for Relapse: Two-thirds of relapses occur within the first 3 months of beginning treatment (Marlatt, 1985). Few Patients Follow-Through with continuing care recommendations. Few Patients Follow-Through with continuing care recommendations.

5 VAMC Aftercare Rates Only 54% of VA patients attend 1 or more aftercare sessions (Fortney et al., 1995). Only 54% of VA patients attend 1 or more aftercare sessions (Fortney et al., 1995). Only 20% of VA patients attend 2 or more aftercare sessions in the first month of aftercare (Peterson et al., 1994). Only 20% of VA patients attend 2 or more aftercare sessions in the first month of aftercare (Peterson et al., 1994).

6 Minimum Effective Dose of SUD Treatment? Treatment of less than 3 months is typically ineffective (Ersoff et al., 1996; Simpson et al., 1997 & 1999). Treatment of less than 3 months is typically ineffective (Ersoff et al., 1996; Simpson et al., 1997 & 1999). Treatment is most effective when at least 7 to 12 months are received (Moos et al., 1999; Ritscher et al., 2002). Treatment is most effective when at least 7 to 12 months are received (Moos et al., 1999; Ritscher et al., 2002).

7 What Does Aftercare Add? 0 Months1-3 Months4-6 Months7+ Months Months in Aftercare *source:Moos, Finney, Ouimette, & Suchinsky, 1999.

8 What Does AA or NA Add? None1-9 Meetings Number of AA/NA Meetings *source:Moos, Finney, Ouimette, & Suchinsky, Meetings30+AA/NA

9 Cause and Effect? Interventions that increase the duration of treatment typically show improved treatment outcome compared to standard care.

10 Research Questions? Can we increase continuing care adherence using clinic- friendly strategies? Can we increase continuing care adherence using clinic- friendly strategies? Does increased continuing care adherence result in improved treatment outcome? Does increased continuing care adherence result in improved treatment outcome?

11 The CPR Intervention Contracting + Prompting + Reinforcing SUD continuing care attendance Contracting + Prompting + Reinforcing SUD continuing care attendance Goal = Keep patients in treatment for at least 3 months, the minimum amount of time associated with positive treatment outcome. Goal = Keep patients in treatment for at least 3 months, the minimum amount of time associated with positive treatment outcome.

12 Contracting, Prompting and Reinforcing Continuing Care Attendance (CPR) Motivational Contract providing abstinence rates associated with continuing care participation. Motivational Contract providing abstinence rates associated with continuing care participation. Prompts for attendance with feedback on progress toward reinforcers/goals. Prompts for attendance with feedback on progress toward reinforcers/goals. Social Reinforcement of aftercare attendance. Social Reinforcement of aftercare attendance.

13 CPR: Contracting Conducted during individual therapy prior to completion of initial intensive treatment. Conducted during individual therapy prior to completion of initial intensive treatment. Brief- 20 minutes, or less. Brief- 20 minutes, or less. First contract for first 3 months of group and individual therapy, and AA or NA. First contract for first 3 months of group and individual therapy, and AA or NA. Second contract for remainder of 1 year. Second contract for remainder of 1 year.

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15 Welcome letter prior to first aftercare session. Welcome letter prior to first aftercare session. Automated phone reminder prior to all appointments. Automated phone reminder prior to all appointments. Phone call and letter from therapist for missed appointments. Phone call and letter from therapist for missed appointments. Appointment cards prior to all appointments, containing feedback on progress toward next reinforcer. Appointment cards prior to all appointments, containing feedback on progress toward next reinforcer. CPR: Prompting

16 Appointment Card Prompt

17 90-Days of Treatment Certificate- 28 days residential program plus at least 6 out of 9 weeks of aftercare group therapy and 2 monthly individual therapy sessions. 90-Days of Treatment Certificate- 28 days residential program plus at least 6 out of 9 weeks of aftercare group therapy and 2 monthly individual therapy sessions. 4 Months of Treatment Medallion- above plus 2 group sessions and 1 individual therapy session in month 4. 4 Months of Treatment Medallion- above plus 2 group sessions and 1 individual therapy session in month 4. 1 Year of Treatment Certificate and Medallion for completing 1 Year of treatment- the above plus 8 months of aftercare (monthly individual therapy and twice monthly group therapy). 1 Year of Treatment Certificate and Medallion for completing 1 Year of treatment- the above plus 8 months of aftercare (monthly individual therapy and twice monthly group therapy). CPR: Social Reinforcement

18 90 DAYS John 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, 2003JanetMcElligott, LCSW

19 “Improving Substance Abuse Treatment Aftercare Adherence and Outcome” Lash, Stephens, Burden, Grambow, DeMarce, Jones, Lozano, Jeffreys, Fearer, & Horner (in press). Psychology of Addictive Behaviors

20Participants 150 graduates of the Salem VA SARRTP 150 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.

21 Design & Hypotheses Clinical trial at the Salem VA SARRTP. 150 participants blocked on SUD diagnosis and randomly assigned to CPR or STX. STX has routine clinical contract, prompts, and reinforcement. Clinical trial at the Salem VA SARRTP. 150 participants blocked on SUD diagnosis and randomly assigned to CPR or STX. STX has routine clinical contract, prompts, and reinforcement. Hypothesized that CPR would produce greater adherence to continuing care and improved treatment outcome than STX. Hypothesized that CPR would produce greater adherence to continuing care and improved treatment outcome than STX. Assessed at baseline, 3-, 6- and 12-month follow-up interviews using Form-90, biochemical substance use screens, collateral report, & medical records. Assessed at baseline, 3-, 6- and 12-month follow-up interviews using Form-90, biochemical substance use screens, collateral report, & medical records.

22 ASI Problem Index Scores

23 Participant Diagnoses

24 Follow-up Rates **p=.04

25 The Impact of CPR on Treatment Adherence

26 Began Aftercare? p =.020

27 SUD Continuity of Care Goal in the VA System Retain VA patients treated for SUDs for at least 2 sessions each month for at least 3 months. Retain VA patients treated for SUDs for at least 2 sessions each month for at least 3 months. Goal is to have at least 32% of each VA’s patients meet this performance standard. Goal is to have at least 32% of each VA’s patients meet this performance standard. Average VA score: 27% (FY nd Quarter). Average VA score: 27% (FY nd Quarter).

28 p =.022 SUD Continuity of Care Performance Measure

29 SUD Continuity of Care Performance Measure

30 Monthly Aftercare Attendance (at least 2 sessions/month) p <.023 Months

31 Survival Analysis- Time in Treatment p <..02

32 The Impact of CPR on Support Group Adherence

33 Began AA or NA? p =.65

34 Number of Days of AA or NA Meetings p =.74p =.27p =.19p =.02

35 The Impact of CPR on Treatment Outcome

36 Abstinence at 12 Months p =.03

37 1) Treatment condition (CPR vs. STX) has an effect on outcome. 1) Treatment condition (CPR vs. STX) has 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) Controlling for attendance, the effect of CPR on abstinence is reduced. 4) Controlling for attendance, the effect of CPR on abstinence is reduced. Does Attendance Mediate Outcome?

38 % of Days Using Substances p=.41p=.72p=.29

39 Summary of Results CPR increases continuing care adherence compared to STX. CPR increases continuing care adherence compared to STX. 15% increase in initiation of aftercare. 15% increase in initiation of aftercare. 53% increase in the SUD COC performance measure. 53% increase in the SUD COC performance measure. 33% increase in time in treatment 33% increase in time in treatment X Did Not Increase AA/NA attendance.

40 CPR improves abstinence rates at 1 year CPR improves abstinence rates at 1 year compared to standard care. 57% increase in abstinence rates at 1 year in preliminary findings. 57% increase in abstinence rates at 1 year in preliminary findings. X No decrease in the percentage of days using substances at 12 months

41 Highlights Clinic-friendly intervention increases treatment adherence, including performance on the SUD COC performance measure. Clinic-friendly intervention increases treatment adherence, including performance on the SUD COC performance measure. CPR results in increased abstinence rates at 1 year follow-up. CPR results in increased abstinence rates at 1 year follow-up.

42 Our Plans Training in VISN 6. Training in VISN 6. Downloadable materials posted on a VA website ( Downloadable materials posted on a VA website ( Automate attendance tracking, prompting, and therapist materials. Automate attendance tracking, prompting, and therapist materials. Make reinforcers more potent, frequent, and immediate. Make reinforcers more potent, frequent, and immediate. Outpatient Trial- does this work with intensive outpatient treatment? Outpatient Trial- does this work with intensive outpatient treatment? Multi-site Trial. Multi-site Trial.

43 Questions & Comments…

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