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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.
                                                                                  1
     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.
                                                      2
                                                 .




   Clinical trial at the Salem VAMC comparing
    CPR to Standard Treatment (STX).

   Compare CPR vs. STX on Continuing Care
    Attendance & Treatment Outcome.




                                                 3
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.
                                                  4
 VAMC Aftercare Rates

 Only54% 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).
                                            5
    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).
                                           6
What Does Aftercare Add?
70                                                     65
     % ABSTINENT at 1 YEAR
60
50                                      43
40      34            34
30
20
10
0
     0 Months   1-3 Months         4-6 Months       7+ Months
                Months in Aftercare
                *source:Moos, Finney, Ouimette, &               7
                Suchinsky, 1999.
What Does AA or NA Add?
80
     % ABSTINENT FOR 1 YEAR                                  67
70
60                                         52
50
40
       29               31
30
20
10
 0

      None        1-9 Meetings 10-29 Meetings30+AA/NA

        Number of AA/NA Meetings
        *source:Moos, Finney, Ouimette, & Suchinsky, 1999.        8
        Cause and Effect?
Interventions that increase the duration of
treatment typically show improved
treatment outcome compared to standard
care.




                                         9
Research Questions?
 Can we increase continuing
 care adherence using clinic-
 friendly strategies?

 Does increased continuing
 care adherence result in
 improved treatment outcome?

                                10
      The CPR Intervention
            + Prompting + Reinforcing
 Contracting
 SUD continuing care attendance

 Goal = Keep patients in treatment for at
 least 3 months, the minimum amount of
 time associated with positive treatment
 outcome.
                                             11
    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.
                                                 12
              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.
                                                     13
14
            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.
                                                   15
Appointment Card Prompt




                          16
       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).              17
       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, 2003                Janet McElligott LCSW    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




                                                   19
                   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.
                                                       20
        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.
                                                    21
ASI Problem Index Scores
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
  0
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                         National Sample           Our Sample
                                                                                      22
      Participant Diagnoses
80%
70%
60%
50%
40%
30%
20%
10%
 0%
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                        National Sample Our Sample                           23
       Follow-up Rates
100%
 90%
 80%                                      STX
 70%
 60%                                      CPR
 50%
 40%                                   **p= .04
 30%
 20%
 10%
  0%
       3




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                                                  24
The Impact of CPR on
Treatment Adherence



                       25
                                   Began Aftercare?
                             100
Percentage of Veterans Who



                              90
                              80
     Began Aftercare




                              70
                              60      82.7      94.7
                              50
                              40
                              30
                              20
                              10
                               0
                                      STX       CPR    p = .020
                                                              26
      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).


                                                  27
                                      SUD Continuity of Care
                                       Performance Measure
% of Veterans Meeting the SUD COC




                                    60%

                                    50%
       Performance Measure




                                    40%

                                    30%

                                    20%    36%        55%

                                    10%

                                    0%
                                           STX        CPR   p =28
                                                                .022
                                     SUD Continuity of Care
                                      Performance Measure
% of Veterans Meeting the SUD COC




                                    60%

                                    50%
       Performance Measure




                                    40%

                                    30%

                                                             36%   55%
                                    20%       27%
                                    10%

                                    0%
                                          National Average   STX   CPR   29
  Monthly Aftercare Attendance
   (at least 2 sessions/month)
90%
80%
70%
60%
50%
                                                    STX
40%                                                 CPR
30%
20%
10%
 0%
      2   3   4   5   6   7   8    9   10 11 12
                                                      .023
                                                  p < 30
                          Months
Survival Analysis- Time in Treatment
                            6
 Mean Months in Treatment
    Prior to Discharge



                            5

                            4

                            3   4.4   5.5
                            2

                            1

                            0
                                STX   CPR
                                                ..02
                                            p < 31
 The Impact of CPR on
Support Group Adherence



                      32
                                   Began AA or NA?
                             100
Percentage of Veterans Who



                              90
                              80
     Began Aftercare




                              70
                              60
                              50      74.1     77.8
                              40
                              30
                              20
                              10
                               0
                                      STX      CPR    p = .6533
  Number of Days of AA or NA
           Meetings
14.0
12.0
10.0
 8.0
                                                STX
 6.0                                            CPR
 4.0
 2.0
 0.0
       Baseline 3 Months 6 Months     1 Year
        p = .02   p = .19   p = .74   p = .27   34
The Impact of CPR on
 Treatment Outcome



                   35
                   % of Veterans Abstinent
              (during the last 3 Months) at the 12-
                  month Follow-up Interview




          0
                10
                       20
                                   30
                                        40
                                             50
                                                      60




    STX
                        35.5




    CPR
                            55.7
                                                           Abstinence at 12 Months




  =
p36 .03
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.                37
% of Days Using Substances
 25%

 20%

 15%
                                         STX
 10%                                     CPR

 5%

 0%
       3 Months   6 Months   12 Months
         p= .41     p= .72    p=.29       38
        Summary of Results
 CPRincreases 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.

                                             39
 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



                                               40
             Highlights
                intervention increases
 Clinic-friendly
 treatment adherence, including
 performance on the SUD COC
 performance measure.

 CPR  results in increased abstinence
 rates at 1 year follow-up.
                                         41
                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.
                                              42
Questions & Comments…

  Steven.Lash@va.gov




                        43
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