Improving Substance Abuse Treatment Aftercare Adherence and Outcome
Steven J. Lash PhD
VA Medical Center
Salem, VA
Funding Period: August 2001 - January 2005

BACKGROUND/RATIONALE:
Although substance abuse treatment continuing care participation is strongly related to positive treatment outcomes, participation rates are low and few interventions have been developed that improve continuing care adherence and outcome.

OBJECTIVE(S):
The objectives of the study were: 1) to compare the effectiveness of an aftercare intervention consisting of a participation contract, attendance prompts, and attendance reinforcers (CPR) to a standard treatment (STX) on adherence to therapy; and 2) to assess the effects of this intervention on treatment outcome

METHODS:
We recruited 150 veterans from the Salem VAMC’s SARRTP who could participate in aftercare. Our population is similar to those in other VA’s (97% male, 54% Caucasian, 46% minority, 49 years mean age, 44% alcohol dependent only, 56% drug dependent, and 44% with a dual diagnosis). In this randomized clinical trial, treatment adherence and outcome were measured at baseline and 3-, 6- and 12-months after participants entered treatment using interviews, questionnaires, alcohol and drug screens, VA medical records, and therapist ratings. The study design is a repeated measures nested cohort design, with an intervention and a standard care group. The primary outcome, abstinence rate, will be analyzed using a logistic regression model in which the parameters of interest are estimated using Generalized Estimating Equations (GEE).

FINDINGS/RESULTS:
We enrolled 96% of the participants that we had projected to enroll and the follow-up rates were high (80%, 81% and 79% for the 3-, 6- and 12-month interviews, respectively). Final data analysis indicates the duration of aftercare treatment was significantly better in the CPR group. Among participants in the CPR condition, 55% received at least 4 months of treatment (the SUD continuity of care performance measure), compared to 36% of the STX group (p = .02). Similarly, the amount of time in treatment was longer in the CPR than the STX group (188.2 vs. 148.3 days; p = .03). However, no significant increase was found on the frequency of support group participation [i.e., Alcoholics Anonymous (AA) or Narcotics Anonymous (NA); p = .14]. Additionally, compared to STX, the CPR participants were more likely to be abstinent at the 12-month follow-up interview (56% vs. 36%; p. = .03). However, the CPR group did not have a lower percentage of days using alcohol or drugs than the STX group (16% vs. 23%, p = .29). Mediational analyses indicate that the increases in attendance mediated, in part, the impact of CPR on 1-year abstinence rates.

IMPACT:
CPR produced meaningful improvements in adherence to VA aftercare therapy and this translated into improved 1-year abstinence rates. Compared to VA averages, CPR produced significant improvements on the SUD continuity of care performance measure and 1-year abstinence rates. Furthermore, CPR offers a practical and portable means to improve participation and outcome for individuals seeking SUD treatment within the VAMC. The intervention and the study findings have been presented during a national VAMC teleconference on continuity of care in substance use disorder treatment, as well as at several national conferences. The treatment manual and materials have been made available through a VAMC website and have been adopted as part of the treatment program at a number of VAs. Dissemination efforts are ongoing. Currently, a Microsoft Access program is being developed for distribution to automatize the generation of materials and instructions for both therapists and patients. Finally, the CPR intervention has been identified as part of the action plan being developed by the SUD QUERI for enhancing retention in continuing specialty SUD care.

PUBLICATIONS:

Journal Articles

1. Lash SJ, Stephens RS, Burden JL, Grambow SC, Demarce JM, Jones ME, Lozano BE, Jeffreys AS, Fearer SA, Horner RD. Contracting, prompting, and reinforcing substance use disorder continuing care: a randomized clinical trial. Psychology of Addictive Behaviors. 2007; 21(3): 387-97.
2. Lash J, Burden L, Fearer A. Contracting, Prompting and Reinforcing Substance Abuse Treatment Aftercare Adherence. Journal of Drug Addiction, Education and Eradication. 2007; 2(3/4): 455-490.
3. Lash SJ, Burden JL, Monteleone BR, Lehmann LP. Social reinforcement of substance abuse treatment aftercare participation: Impact on outcome. Addictive Behaviors. 2004; 29(2): 337-42.

DRA: Health Services and Systems, Substance Abuse, Addictive Disorders
DRE: Quality of Care, Rehabilitation, Resource Use and Cost
Keywords: Behavior (patient)
MeSH Terms: none