Donna M. Coviello

A Randomized Trial of Extended Telephone-Based Continuing Care for Alcohol Dependence: Within-Treatment Substance Use Outcomes.

OBJECTIVE The study tested whether adding up to 18 months of telephone continuing care, either as monitoring and feedback (TM) or longer contacts that included counseling (TMC), to intensive outpatient programs (IOPs) improved outcomes for alcohol-dependent patients. METHOD Participants (N = 252) who completed 3 weeks of IOP were randomized to up to 36 sessions of TM (M = 11.5 sessions), TMC (M = 9.1 sessions), or IOP only (treatment as usual [TAU]). Quarterly assessment of alcohol use (79.9% assessed at 18 months) was corroborated with available collateral reports (N = 63 at 12 months). Participants with cocaine dependence (N = 199) also provided urine samples. RESULTS Main effects favored TMC over TAU on any alcohol use (odds ratio [OR] = 1.88, CI [1.13, 3.14]) and any heavy alcohol use (OR = 1.74, CI [1.03, 2.94]). TMC produced fewer days of alcohol use during Months 10-18 and heavy alcohol use during Months 13-18 than TAU (ds = 0.46-0.65). TMC also produced fewer days of any alcohol use and heavy alcohol use than TM during Months 4-6 (ds = 0.39 and 0.43). TM produced lower percent days alcohol use than TAU during Months 10-12 and 13-15 (ds = 0.41 and 0.39). There were no treatment effects on rates of cocaine-positive urines. CONCLUSIONS Adding telephone continuing care to IOP improved alcohol use outcomes relative to IOP alone. Conversely, shorter calls that provided monitoring and feedback but no counseling generally did not improve outcomes over IOP.

A community-based trial of vocational problem-solving to increase employment among methadone patients

UNLABELLED Unemployment remains a common problem among methadone patients. This study examined the effectiveness of the Vocational Problem-Solving Skills (VPSS) intervention to help unemployed methadone patients obtain employment. METHODS 109 patients were randomly assigned to receive 10 sessions of either VPSS (n=62) or Interpersonal Problem-Solving (IPS) (n=47). Fourteen counselors from two methadone programs were trained to deliver both the VPSS and IPS counseling sessions. RESULTS Overall, 93% (101/109) of the patients completed a 6-month follow-up assessment which revealed that 58.6% (34/58) of patients in the VPSS condition were employed, whereas 37.2% (16/43) in the comparison condition worked (chi-square=4.53, 1 df, p<0.05). However, a multinomial regression equation found that the VPSS intervention did not significantly contribute to the prediction of employment. Other factors such as longer length of previous work experience, 40 years of age or older, treatment site, and baseline patient motivation to work emerged as significant predictors. CONCLUSION Although VPSS alone was not a strong independent predictor of improved employment functioning, improvements in employment functioning were detected at one of the two sites as a function of VPSS.

The Effectiveness of Early Parole to Substance Abuse Treatment Facilities on 24-Month Criminal Recidivism:

This naturalistic study involved 569 offenders who had a history of substance abuse or dependence prior to incarceration, and were subsequently approved for early parole to a community-based substance abuse treatment facility (SATF). Overall 495 offenders were paroled directly to a SATF while 74 were paroled to the community without transfer to a SATF due to prison overcrowding. Criminal history records for all 569 offenders were obtained approximately 24 months following parole. Any new conviction as a result of a new crime committed during the 24-month window following parole to the community was considered a negative outcome. Results found that 22% of offenders paroled to a substance abuse treatment facility (SATF) were convicted of a new crime compared to 34% of offenders paroled directly to the community (chi-square = 4.57, df=1, p=.03). A stepwise logistic regression analysis was conducted to determine how different factors contributed to a new conviction. Overall more prior convictions (p<.001) and lower age (p=.001) were strong significant predictors and cocaine dependence (p=.06) and parole without treatment (p=.08) were predictive of a new conviction. Additionally, offenders who completed treatment were significantly less likely to be convicted of a new crime (11.8% vs. 29%) than those who dropped out of treatment (chi-square = 11.50, df = 1, p<.01). These data suggest that early parole to a SATF could be considered as a viable means to reduce prison sentences for addicted offenders.

A Multisite Pilot Study of Extended-Release Injectable Naltrexone Treatment for Previously Opioid-Dependent Parolees and Probationers

A feasibility study was conducted to pilot test the ability of 5 sites to recruit, treat, and retain opioid-dependent offenders in a trial of extended-release injectable naltrexone (XR-NTX). The participants, 61 previously opioid-dependent individuals under legal supervision in the community, received up to 6 monthly injections of Depotrex brand naltrexone and completed a 6-month follow-up interview. Six-month outcomes showed that those who completed treatment had significantly fewer opioid-positive urines and were less likely to have been incarcerated than those who had not completed treatment. The findings indicate that XR-NTX holds promise as a feasible, effective treatment option for opioid-dependent offenders.

A randomized trial of oral naltrexone for treating opioid-dependent offenders.

Offenders with a history of opioid dependence are a particularly difficult group to treat. A large proportion of offenders typically relapse shortly after release from prison, commit drug-related crimes, and then are arrested and eventually re-incarcerated. Previous research demonstrated that oral naltrexone was effective in reducing opioid use and preventing recidivism among offenders under federal supervision. The 111 opioid-dependent offenders in this study were under various levels of supervision that included county and federal probation/parole, a treatment court, an alternative disposition program, and an intermediate punishment program. Subjects were randomly assigned to receive 6 months of either 300 mg per week of oral naltrexone plus standard psychosocial treatment as usual (n = 56) or standard psychosocial treatment as usual (TAU) without naltrexone (n = 55). While the TAU subjects who remained in treatment used more opioids than the naltrexone subjects who remained, the high dropout rate for both groups made it difficult to assess the effectiveness of naltrexone. The study provides limited support for the use of oral naltrexone for offenders who are not closely monitored by the criminal justice system.

Extended Telephone-Based Continuing Care for Alcohol Dependence: 24 Month Outcomes and Subgroup Analyses

AIMS To determine whether 18 months of telephone continuing care improves 24-month outcomes for patients with alcohol dependence. Subgroup analyses were performed to identify patients who would benefit most from continuing care. DESIGN Comparative effectiveness trial of continuing care that consisted of monitoring and feedback only (TM) or monitoring and feedback plus counseling (TMC). Patients were randomized to treatment as usual (TAU), TAU plus TM or TAU plus TMC, and followed quarterly for 24 months. SETTING Publicly funded intensive out-patient programs (IOP). PARTICIPANTS A total of 252 alcohol-dependent patients (49% with current cocaine dependence) who completed 3 weeks of IOP. MEASUREMENTS Percentage of days drinking, any heavy drinking and a composite good clinical outcome. FINDINGS In the intent-to-treat sample, group differences in alcohol outcomes out to 18 months favoring TMC over TAU were no longer present in months 19-24. There was also a non-significant trend for TMC to perform better than usual care on the good clinical outcome measure (60% vs. 46% good clinical outcome in months 19-24). Overall significant effects favoring TMC and TM over TAU were seen for women; and TMC was also superior to TAU for participants with social support for drinking, low readiness to change and prior alcohol treatments. Most of these effects were obtained on at least two of three outcomes. However, no effects remained significant at 24 months. CONCLUSIONS The benefits of an extended telephone-based continuing care programme to treat alcohol dependence did not persist after the end of the intervention. A post-hoc analysis suggested that women and individuals with social support for drinking, low readiness to change or prior alcohol treatments may benefit from the intervention.

Randomized Trial of Continuing Care Enhancements for Cocaine Dependent Patients Following Initial Engagement

OBJECTIVE The effects of cognitive-behavioral relapse prevention (RP), contingency management (CM), and their combination (CM + RP) were evaluated in a randomized trial with 100 cocaine-dependent patients (58% female, 89% African American) who were engaged in treatment for at least 2 weeks and had an average of 44 days of abstinence at baseline. METHOD The participants were from intensive outpatient programs, which provide 10 hr per week of group counseling. The CM protocol provided gift certificates (maximum value

An adaptive approach for identifying cocaine dependent patients who benefit from extended continuing care

1,150; mean received =

Predictors of Drug Treatment Completion Among Parole Violators

740) for cocaine-free urines over 12 weeks on an escalating reinforcement schedule, and weekly individual RP sessions were offered for up to 20 weeks. Average number of RP sessions attended was 3 in RP and 13 in CM + RP. RESULTS Generalizing estimation equation analyses over 18 months postrandomization showed significant effects for CM (but not RP) on urine toxicology and self-reported cocaine use (p = .05), with no significant CM x RP interactions. Secondary analyses indicated CM + RP produced better cocaine urine toxicology outcomes at 6 months than treatment as usual, odds ratio [OR] = 3.96 (1.33, 11.80), p < .01, and RP, OR = 4.89 (1.51, 15.86), p < .01, and produced better cocaine urine toxicology outcomes at 9 months than treatment as usual, OR = 4.21 (1.37, 12.88), p < .01, and RP, OR = 4.24 (1.32, 13.65), p < .01. Trends also favored CM + RP over CM at 6 months, OR = 2.93 (0.94, 9.07), p = .06, and 9 months, OR = 2.93 (0.94, 9.10), p = .06. Differences between the conditions were not significant after 9 months. CONCLUSIONS These results suggest CM can improve outcomes in cocaine-dependent patients in intensive outpatient programs who have achieved initial engagement, particularly when it is combined with RP.

The effectiveness of two intensities of psychosocial treatment for cocaine dependence

OBJECTIVE Study tested whether cocaine dependent patients using cocaine or alcohol at intake or in the first few weeks of intensive outpatient treatment would benefit more from extended continuing care than patients abstinent during this period. The effect of incentives for continuing care attendance was also examined. METHOD Participants (N = 321) were randomized to treatment as usual (TAU), TAU and telephone monitoring and counseling (TMC), or TAU and TMC plus incentives (TMC+). The primary outcomes were (a) abstinence from all drugs and heavy alcohol use and (b) cocaine urine toxicology. Follow-ups were at 3, 6, 9, 12, 18, and 24 months. RESULTS Cocaine and alcohol use at intake or early in treatment predicted worse outcomes on both measures (ps ≤ .0002). Significant effects favoring TMC over TAU on the abstinence composite were obtained in participants who used cocaine (odds ratio [OR] = 1.95 [1.02, 3.73]) or alcohol (OR = 2.47 [1.28, 4.78]) at intake or early in treatment. A significant effect favoring TMC+ over TAU on cocaine urine toxicology was obtained in those using cocaine during that period (OR = 0.55 [0.31, 0.95]). Conversely, there were no treatment effects in participants abstinent at baseline and no overall treatment main effects. Incentives almost doubled the number of continuing care sessions received but did not further improve outcomes. CONCLUSION An adaptive approach for cocaine dependence in which extended continuing care is provided only to patients who are using cocaine or alcohol at intake or early in treatment improves outcomes in this group while reducing burden and costs in lower risk patients.