# Presentation: 543324

## 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.**

## 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.

## .

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

## 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.

## 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).

## 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).

## What Does Aftercare Add?

**What Does Aftercare Add?**

- _0 Months_

- _1-3 Months_

- _4-6 Months_

- _7+ Months_

- Months in Aftercare *source:Moos, Finney, Ouimette, & Suchinsky, 1999.* *

## What Does AA or NA Add?

**None**

**1-9 Meetings**

- Number of  AA/NA Meetings *source:Moos, Finney, Ouimette, & Suchinsky, 1999.* *

**10-29 Meetings**

**30+AA/NA**

## Cause and Effect?

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

## Research Questions?

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

## The CPR Intervention

**C**ontracting + **P**rompting + **R**einforcing SUD continuing care attendance
- Goal = Keep patients in treatment for at least 3 months, the minimum amount of time associated with positive treatment outcome.

## 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.

## 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.

## Slide 14

## 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.

- 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.

***CPR:*** **Prompting**

## Appointment Card Prompt

## 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).

**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).

*CPR:* **Social Reinforcement**

## Slide 18

## “Improving Substance Abuse Treatment Aftercare Adherence and Outcome”

- Lash, Stephens, Burden, Grambow, DeMarce, Jones, Lozano, Jeffreys, Fearer, & Horner (in press). _Psychology of Addictive Behaviors_

## 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.

## 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.**

## ASI Problem Index Scores

## Participant Diagnoses

## Follow-up Rates

- **_p_= .04

## The Impact of CPR on Treatment Adherence 

## Began Aftercare? 

- _p _=  .020

## 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 VA’s     patients meet this performance standard.
- Average VA score:  27% (FY 2004 2nd Quarter).

## SUD Continuity of Care Performance Measure

- _p_ = .022

**SUD Continuity of Care Performance Measure**

## SUD Continuity of Care Performance Measure

## Monthly Aftercare Attendance(at least 2 sessions/month)

- _p_ < .023

- _Months__ _

## Survival Analysis- Time in Treatment

- _p_ < ..02

## The Impact of CPR on Support Group Adherence 

## Began AA or NA? 

- _p _=  .65

## Number of Days of AA or NA Meetings

- _p_ = .74

- _p_ = .27

- _p_ = .19

- _p_ = .02

## The Impact of CPR on Treatment Outcome

## Abstinence at 12 Months

- _p_ = .03

## 
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.

**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.**

**Does Attendance Mediate Outcome?**

## % of Days Using Substances  

- _p_= .41

- _p_= .72

- _p_=.29

## 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.

## 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

## 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.

## Our Plans

- Training in VISN 6.
- Downloadable materials posted on a VA website (http:vaww.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.

## Questions & Comments...   Steven.Lash@va.gov

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