BACKGROUND/RATIONALE:
BACKGROUD/RATIONALE: Although substance use disorder (SUD) 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. The Contracts, Prompts, and Social Reinforcement (CPR) intervention meaningfully impacts aftercare adherence and abstinence rates, and it is particularly effective for individuals with co-morbid psychiatric disorders. However, CPR has not impacted early abstinence rates, other important measures of treatment outcome, or AA/NA support group attendance. Furthermore, its generalizability and cost effectiveness have not been established.
OBJECTIVE(S):
OBJECTIVES: The CPR intervention has been modified to include social reinforcement of abstinence and improved prompting of AA/NA attendance (CPR+). The current multi-site randomized clinical trial examines the effectiveness of CPR+ compared to standard treatment (STX) with 4 specific goals: 1) to assess its impact on adherence to continuing care (i.e., AA/NA and aftercare therapy), 2) to assess its effect on 1-year abstinence rates, 3) examine its cost-effectiveness, and 4) to examine its generalizability across VA sites and participants with comorbid psychiatric disorders.
METHODS:
METHODS: We have recruited 183 veterans seeking residential treatment at the Salem and Jackson VAMCs over one year, and are assessing their treatment adherence and outcome over a 1-year period, using assessors blinded to participants' treatment condition. At each site participants were blocked on SUD diagnosis, the presence of a co-morbid psychiatric disorder, and selected aftercare therapy group time prior to randomization to STX or CPR+. Participants will be primarily African-American (59%) and Caucasian (40%) male (96%) veterans. Co-morbid psychiatric disorders will be present in 45% of the sample, and 38% will be alcohol dependent only, while 62% will be drug dependent (with or without alcohol dependence). Our primary hypothesis is that the CPR+ group will have higher 1-year abstinence rates compared to the STX group. Our secondary hypotheses are that the CPR+ will be particularly effective for individuals with co-morbid psychiatric disorders, that the CPR+ group will remain in AA/NA and aftercare for a longer duration, have fewer days of substance use, and hospitalizations, and show greater incremental cost effectiveness ratios. Treatment outcome will be measured 3-, 6-, and 12-months after participants enter treatment and compared to baseline levels using the Form-90 Interview, the Addiction Severity Index (ASI), questionnaire responses, and substance use screens. Treatment adherence will be measured using VA databases, medical records, therapist ratings, and questionnaire responses. Abstinence rates will be analyzed using a logistic regression model in which the parameters of interest are estimated using Generalized Estimating Equations. Secondary outcomes will be analyzed using both marginal and linear mixed-effects models as appropriate.
FINDINGS/RESULTS:
FINDINGS/RESULTS: Participant recruitment was complete in April 2008. Final follow-up interviews will be completed in June 2009. The final report will be completed by March 2010. The primary results and additional papers will be submitted during 2010.
IMPACT:
IMPACT:
Based on past research and enhancements in the intervention, it is hypothesized that CPR+ will produces meaningful improvements in adherence to VA aftercare therapy, AA and NA participation, and that this will translate into improved short and long term abstinence rates. Furthermore, it is hypothesized that these results will generalize across VA sites and to individuals with comorbid psychiatric disorders. If these hypotheses are supported, CPR+ offers a practical and portable means to improve participation and outcome for individuals seeking SUD treatment within the VAMC. Currently, we are beginning to develop plans for a regional demonstration project.
PUBLICATIONS:
Journal Articles
- 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.
