What does research tell us about effective continuing care?

What does research tell us about effective continuing care?

• What does research tell us about effective continuing care?

• Potential role of the telephone in continuing care

• Initial evaluation of a telephone continuing care protocol

• Was it effective?
• How did it work?
• Whom is it contraindicated for?

Development of current telephone continuing care intervention

• Development of current telephone continuing care intervention

• Components
• Evaluation with alcohol dependent patients

• Ongoing work with cocaine dependent patients

• Methods to increase engagement and retention
• Preliminary outcomes
• New project

• Final Conclusions

Biological

• Biological

• Neurocognitive factors
• Genetic factors

• Behavioral

• Poor coping/life skills
• Interpersonal problems

• Environmental

• Poor social support for recovery
• High risk neighborhoods

• Co-occurring disorders

• Depression
• PTSD

In review of continuing care literature (McKay, 2009), factors associated with significant effects were:

• In review of continuing care literature (McKay, 2009), factors associated with significant effects were:

• Planned TX durations of > 12 months
• More active efforts to deliver TX to patients
• More recent studies!

Finding a way to deliver extended treatments that are:

• Finding a way to deliver extended treatments that are:

• Effective
• Economical
• Feasible/practical

Potential to promote better long-term engagement and participation because:

• Potential to promote better long-term engagement and participation because:

• Convenient for client
• Individualized attention
• Reduces stigma of weekly trips to the treatment program

Studies suggest the telephone can be effective in delivering treatment:

• Studies suggest the telephone can be effective in delivering treatment:

• Addiction (Foote & Erfurt, 1991; McKay et al., 2005)
• Smoking (Lichtenstein et al., 1996)
• Depression (Baer et al., 1995; Simon et al., 2004)
• OCD (Greist et al., 1998)
• Panic and Anxiety (Rollman et al., 2005)
• Bulimia (Hugo et al., 1999)
• Cardiac care (Jerant et al., 2001; Riegel et al., 2002)

Patients:

• Patients:

• 359 graduates of 4-week IOP programs
• Alcohol and/or cocaine dependent

• Continuing care treatment conditions:

• Standard group counseling (STND)
• Individualized relapse prevention (RP)
• brief telephone-based counseling (TEL)

• Followed for 24 months

Failure to achieve key goals while in IOP:

• Failure to achieve key goals while in IOP:

• Any alcohol use in prior 30 days
• Any cocaine use in prior 30 days
• Attendance at < 12 self-help meetings in prior 30 days
• Social support < median for the sample
• Does not have goal of absolute abstinence
• Self-efficacy < 80%

• Current dependence on both alcohol and cocaine

• (each item: yes=1, no=0)

Patients: Patients with current alcohol dependence recruited from IOPs after 3-4 weeks of treatment (50% current/75% lifetime cocaine dependence)

• Patients: Patients with current alcohol dependence recruited from IOPs after 3-4 weeks of treatment (50% current/75% lifetime cocaine dependence)

• Treatment conditions:

• Treatment as usual (TAU)
• TAU plus TEL monitoring & feedback only (TM; 18 months)
• TAU plus TEL monitoring and adaptive counseling (TMAC; 18 mo.)

• Outcomes assessed over 24 months

• 252 randomized participants in the study

Reasons for exclusion (most common)

• Reasons for exclusion (most common)

• No show for baseline interviews N=280
• No current ETOH dependence N=181
• Past 4 weeks in IOP N=109
• Not interested N=64
• Did not complete baseline N=47
• Severe psychiatric problems N=35
• IV heroin / opiate dependent N=29
• No phone N=15

Common ingredients of effective treatments

• Common ingredients of effective treatments

• Monitoring of symptoms and progress
• Identification of problems and barriers to recovery
• Emphasis on concrete planning and problem solving
• Activate the patient—take charge of own recovery

Frequency: weekly at first, titrated to bimonthly

• Frequency: weekly at first, titrated to bimonthly

• Each call starts with a brief “progress assessment” that assesses negative and positive factors and yields overall risk score (low, moderate, high)

• Risk factors
• Failure to attend medical appointments
• Depression
• Low self-efficacy (low confidence in coping)
• Craving or obsessive thoughts of using
• In high risk situations

Protective factors

• Protective factors
• Good coping skills
• Pro-recovery social activities
• Having and working toward personal goals
• Attending AA/NA meetings
• Regular contact with a sponsor
• General status items
• Any alcohol or drug use
• IOP attendance status

Structure and content of the calls:

• Structure and content of the calls:

• Provide feedback on risk level
• Review progress/goals from last call
• 3. Identify upcoming high-risk situations
• 4. Select target for remainder of call
• 5. Brief problem-solving regarding target concern(s)
• 6. Set goal(s) for interval before next call
• 7. Suggest change in level of care if warranted

Most were MA-level, with at least some experience in addictions counseling

• Most were MA-level, with at least some experience in addictions counseling

• Ability to engage patient, listen closely, be lively, and set limits is important

• All sessions are audio-taped, which is used for supervision and rating of adherence

Follow-ups at 3, 6, 9, 12, 15, 18, 21, 24 months

• Follow-ups at 3, 6, 9, 12, 15, 18, 21, 24 months

• Follow-up rate over 80% out to 15 months, 79% out to 24 months

• Outcomes obtained with:

• TLFB
• Collateral reports
• Urine toxicology

Patients: Cocaine dependent IOP participants still attending in week 2 (N=322)

• Patients: Cocaine dependent IOP participants still attending in week 2 (N=322)

• Treatment conditions:

• Treatment as usual (TAU)
• TAU plus telephone counseling for 24 mo. (TMC)
• TAU plus telephone counseling (24 mo.), plus incentives for participation and cocaine-free urines (first 12 mo) (TMC Plus)

• Outcomes assessed over 24 months

Changes to inclusion/exclusion criteria

• Changes to inclusion/exclusion criteria

• Lifetime cocaine dependence, with some use in last 6 months (current dx not required)
• Have completed 2 vs. 4 weeks of IOP treatment
• Less stringent requirements for ongoing psychiatric follow-up of effected patients

• Result: much higher ratio of enrolled / screened than in prior study

Lengthened face-to-face orientation to 2 sessions

• Lengthened face-to-face orientation to 2 sessions

• Added HIV risk reduction component to orientation

• Provided patients with choice of doing sessions over the telephone or in person

• Greater focus on helping patient stay engaged in IOP, while in that phase of care

• Modified risk assessment

• More conversational in format
• Simpler rules for step up/down
• Lateral as well as vertical adaptations
• Clearer directions for case management activities

Patients receive $10 gift coupon (Target, Walmart, local grocery store chain) for each completed clinical contact

• Patients receive $10 gift coupon (Target, Walmart, local grocery store chain) for each completed clinical contact

• One $10 bonus gift coupon provided for every 3 consecutive contacts completed

• Additional $10 gift coupon for cocaine free urine provided during an in-person stepped care session (e.g., MI or CBT)

• Incentives provided only in year 1 of protocol

• Participants have to come to our research site to receive gift coupons (University rules)

RC1 Challenge grant to test an “enhanced” version of telephone continuing care

• RC1 Challenge grant to test an “enhanced” version of telephone continuing care

• Patients begin at intake
• Incentives are provided for completed contacts
• Cell phones provided if needed
• Patient choice around form of service delivery
• More aggressive linkage to social and recovery supports
• Greater emphasis on development of recovery capital
• Much more aggressive outreach when patients disappear

In IOP graduates, telephone continuing care is at least as effective as standard group counseling and individualized relapse prevention for patients with alcohol and/or cocaine dependence.

• In IOP graduates, telephone continuing care is at least as effective as standard group counseling and individualized relapse prevention for patients with alcohol and/or cocaine dependence.

• Telephone continuing care appears to work in IOP graduates by increasing participation in self-help, and increasing self-efficacy and commitment to abstinence

• Patients who make poor progress while in IOP may require more intensive continuing care before being put on the telephone

The addition of extended, telephone-based continuing care to longer IOPs appears to improve outcomes for patients with alcohol dependence

• The addition of extended, telephone-based continuing care to longer IOPs appears to improve outcomes for patients with alcohol dependence

• In alcohol patients, adding counseling to calls produces stronger effects than monitoring/ feedback alone, relative to standard care

• Most effective disease management in patients with poor social support, low motivation, prior treatments

In cocaine patients, adding incentives to TMC dramatically increases participation rates

• In cocaine patients, adding incentives to TMC dramatically increases participation rates

• Cocaine patients who were still using cocaine or alcohol immediately before IOP or in the first few weeks of IOP benefited to a greater degree from extended telephone continuing care than those who had stopped cocaine and alcohol use.

• Not clear that higher participation rates in patients who received incentives translates into better drug use outcomes.

Access to the telephone can vary considerably

• Access to the telephone can vary considerably

• Without incentives, rates of extended participation may be low. However, the intervention is still effective

Funding from NIDA

• Funding from NIDA

• R01 DA020623
• K02-DA00361

• Funding from NIAAA

• R01 AA014850
• P01-AA016821

• Funding from VHA

McKay, J.R. (2009). Treating substance use disorders with adaptive continuing care. Washington, DC: American Psychological Association

• McKay, J.R. (2009). Treating substance use disorders with adaptive continuing care. Washington, DC: American Psychological Association

• McKay, J.R., Van Horn, D., & Morrison, R. (2010). Telephone continuing care for adults. Center City, MN: Hazelden.

Penn and TRI

• Penn and TRI

• Adam Brooks
• John Cacciola
• Deni Carise
• Donna Coviello
• Michelle Drapkin
• Kevin Lynch
• Tom McLellan
• Dave Oslin
• Debbie Van Horn

James R. McKay, Ph.D.

• James R. McKay, Ph.D.

• Center on the Continuum of Care in the Addictions

• 3440 Market St., Suite 370

• Philadelphia, PA 19104

• [phone]

• [e-mail]

• Center website: http://www.med.upenn.edu/ccc/