Improving SUD Continuity of Care: Bringing Science to Practice

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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
  (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 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.
• 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 Attendance
  Treatment Outcome.

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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..
• 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.

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VAMC Aftercare Rates

• 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).

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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 is most effective when at least 7 to 12
  months are received (Moos et al., 1999 Ritscher
  et al., 2002).

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What Does Aftercare Add?
0 Months
1-3 Months
4-6 Months
7 Months
Months in Aftercare sourceMoos, Finney,
Ouimette, Suchinsky, 1999.
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What Does AA or NA Add?
None
1-9 Meetings
10-29 Meetings
30AA/NA
Number of AA/NA Meetings sourceMoos, Finney,
Ouimette, Suchinsky, 1999.
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Cause and Effect?

• Interventions that increase the duration of
  treatment typically show improved treatment
  outcome compared to standard care.

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Research Questions?

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

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The CPR Intervention

• 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.

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Contracting, Prompting and Reinforcing Continuing
Care Attendance (CPR)

• Motivational Contract providing abstinence rates
  associated with continuing care participation.
• Prompts for attendance with feedback on progress
  toward reinforcers/goals.
• Social Reinforcement of aftercare attendance.

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CPR Contracting

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

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CPR Prompting

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

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Appointment Card Prompt
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CPR Social Reinforcement

• 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.
• 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).

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Improving Substance Abuse Treatment Aftercare
Adherence and Outcome

• Lash, Stephens, Burden, Grambow, DeMarce, Jones,
  Lozano, Jeffreys, Fearer, Horner (in press).
  Psychology of Addictive Behaviors

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Participants

• 150 graduates of the Salem VA SARRTP
• (VA averages in parentheses Moos et al.,
  1999).
• Mean age was 48.6 years (43 years).
• 97 (99) Male.
• 45 (46) Caucasian, 53 (49) African-American,
  
• 1 (5) Other racial groups.
• 13 (19) Married, 65 (56) Separated or
  divorced,
• 20 (23) Single, 3 (2) Widowed.

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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.
• 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.

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ASI Problem Index Scores
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Participant Diagnoses
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Follow-up Rates
p .04
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The Impact of CPR on Treatment Adherence
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Began Aftercare?
p .020
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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.
• Goal is to have at least 32 of each VAs
  patients meet this performance standard.
• Average VA score 27 (FY 2004 2nd Quarter).

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SUD Continuity of Care Performance Measure
p .022
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SUD Continuity of Care Performance Measure
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Monthly Aftercare Attendance(at least 2
sessions/month)
Months
p lt .023
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Survival Analysis- Time in Treatment
p lt ..02
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The Impact of CPR on Support Group Adherence
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Began AA or NA?
p .65
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Number of Days of AA or NA Meetings
p .74
p .27
p .19
p .02
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The Impact of CPR on Treatment Outcome
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Abstinence at 12 Months
p .03
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Does Attendance Mediate Outcome?

• 1) Treatment condition (CPR vs. STX) has an
  effect on outcome.
• 2) CPR affects the attendance.
• 3) Attendance related to Abstinence.
• 4) Controlling for attendance, the effect of CPR
  on abstinence is reduced.

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of Days Using Substances
p .41
p .72
p.29
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Summary of Results

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

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

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Highlights

• 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.

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Our Plans

• Training in VISN 6.
• Downloadable materials posted on a VA website
  (httpvaww.mentalhealth.med.va.gov/).
• Automate attendance tracking, prompting, and
  therapist materials.
• Make reinforcers more potent, frequent, and
  immediate.
• Outpatient Trial- does this work with intensive
  outpatient treatment?
• Multi-site Trial.

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Questions Comments Steven.Lash_at_va.gov
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