Michelle L. Drapkin

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.

Development and Initial Evaluation of the Brief Addiction Monitor (BAM)

This project developed and tested a 17-item monitoring instrument covering important substance use related behaviors to support measurement-based care and outcomes assessment. The study consisted of two phases, an instrument development phase and an initial study to examine its psychometric properties. Participants were 175 patients entering VA outpatient substance abuse treatment. The findings revealed that this Brief Addiction Monitor (BAM) exhibited acceptable characteristics. Exploratory factor analysis yielded three summary factors; recovery protection, physical and psychological problems, and substance use and risk. The root mean square error of approximation estimate was acceptable and the factors had alpha values exceeding or approaching 0.70. All three factors were sensitive to change and had excellent test-retest reliability. Predictive validity was demonstrated for two factors; recovery protection, and substance use and risk. At the item level, there was little indication of inappropriate response patterns. Change over time was significant for most items, and test-retest reliability was acceptable for nearly all items. Additional research is warranted to further establish the BAMs reliability, validity and usefulness.

Motivational interviewing integrated with social network counseling for female adolescents: A randomized pilot study in urban primary care

This study tested the efficacy of a brief preventive intervention for substance use and associated risk behaviors among female adolescent patients of an urban primary care health clinic. We integrated an evidenced-based motivational interviewing (MI) approach with a social network component to develop a 20-minute session, a social network intervention delivered in an MI-consistent style. Female adolescents (N = 28) 14 to 18 years old were recruited, provided consent/assent, were screened, and were randomly assigned to the treatment or control (no treatment) condition. The sample was 82% African American and 18% mixed race, with 32% living below the U.S. poverty line. At 1-month follow-up, teens in the treatment condition reported less trouble due to alcohol use, less substance use before sexual intercourse, less social stress, less offers for marijuana use, and increased readiness to start counseling compared with the teens in the control condition. Results provide support for socially based brief interventions with at-risk urban adolescents.

Nationwide dissemination of contingency management: The veterans administration initiative

BACKGROUND Contingency management (CM) is an empirically validated intervention but one not often applied in practice settings in the US. OBJECTIVES The aim of this article is to describe the Veterans Administration (VA) nationwide implementation of CM treatment. METHODS In 2011, the VA called for integration of CM in its intensive outpatient substance abuse treatment clinics. As part of this initiative, the VA funded training and ongoing implementation support, and it provided direct funds for reinforcers and other intervention costs. RESULTS Over 100 clinics received this funding in 2011, and CM has been implemented in over 70 substance abuse treatment clinics since August 2011. CONCLUSIONS This training and implementation experience has been highly successful and represents the largest scale training in evidence-based treatments for substance use disorders in the VA health care system to date. SCIENTIFIC SIGNIFICANCE This program may serve as a model for training in evidence-based treatments.

Baseline functioning among individuals with posttraumatic stress disorder and alcohol dependence.

Comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD) may lead to a complicated and potentially severe treatment profile. Our study examined 167 individuals with both PTSD and AD compared with 105 individuals with PTSD without an alcohol use disorder (AUD) and 240 individuals with AD without PTSD on baseline psychosocial functioning. We hypothesized that individuals with PTSD/AD would be more socially and functionally impaired than individuals with only one disorder. Results indicated that participants with PTSD/AD were more likely to be unemployed, have less education, and report less income and were less likely to live with a partner than the participants with only a single disorder. However, they did not differ on symptom severity within these disorders (drinking frequency/quantity, PTSD, and anxiety symptoms) with the exception of depression and alcohol craving. This contradicts clinical lore that comorbid patients are more impaired at treatment initiation and adds support for concurrent treatment as not only feasible but also possibly ideal for these patients.

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.

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

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.

Factors in sustained recovery from cocaine dependence

The goal was to identify factors that predicted sustained cocaine abstinence and transitions from cocaine use to abstinence over 24 months. Data from baseline assessments and multiple follow-ups were obtained from three studies of continuing care for patients in intensive outpatient programs (IOPs). In the combined sample, remaining cocaine abstinent and transitioning into abstinence at the next follow-up were predicted by older age, less education, and less cocaine and alcohol use at baseline, and by higher self-efficacy, commitment to abstinence, better social support, lower depression, and lower scores on other problem severity measures assessed during the follow-up. In addition, higher self-help participation, self-help beliefs, readiness to change, and coping assessed during the follow-up predicted transitions from cocaine use to abstinence. These results were stable over 24 months. Commitment to abstinence, self-help behaviors and beliefs, and self-efficacy contributed independently to the prediction of cocaine use transitions. Implications for treatment are discussed.

Moderators of response to telephone continuing care for alcoholism.

OBJECTIVES To evaluate potential moderators of the effect of adding extended telephone monitoring (TM) and telephone monitoring and counseling (TMC) continuing care to treatment as usual (TAU) for alcoholism. Continuing care was predicted to be more effective for patients with severe substance-use histories, poor initial response to treatment, and other risk factors for relapse. METHODS Randomized study with 18-month follow-up. Outcomes were frequency of drinking and any drinking. RESULTS Main effects favored TMC over TAU on alcohol outcomes. However, none of the 11 variables examined moderated these effects. Conversely, main effect and moderator analyses indicated TM was more beneficial than TAU only for women and for participants with lower readiness to change. CONCLUSIONS TMC improves drinking outcomes when added to standard care, regardless of alcohol use history, early response to treatment, or other risk factors for relapse. TM is recommended for women and less motivated patients.

Characteristics and 9-month outcomes of discharged methadone maintenance clients

This study is a secondary data analysis of a clinical trial assessing the effectiveness of outreach case management (OCM) in linking discharged methadone patients back into treatment. The original trial assessed the effectiveness of the OCM intervention compared to a passive referral among methadone clients who needed treatment postdischarge but had not reengaged. The purpose of this study was to assess the characteristics and long-term outcomes of all clients who were discharged from methadone maintenance treatment including those who had reengaged in treatment. A total of 230 methadone clients were interviewed 3 months and then again at 9 months following discharge from treatment. Compared with participants who needed treatment but had not reengaged (NoTx: 56%), those who had successfully reenrolled in treatment (Tx; 44%) were more likely to be female, not married, and unemployed; had a longer history of sedative use; reported more psychiatric hospitalizations; and were originally enrolled in a community-based rather than a Veterans Administration program. Despite having more severe problems, the Tx group had fewer opioid-positive urines and reported less IV drug use at 9 months postdischarge compared to the NoTx group. The findings highlight the importance of rapid treatment reengagement.