Steven J. Lash

Increasing adherence to substance abuse aftercare group therapy

Adherence to aftercare therapy in substance abuse treatment is associated with improved outcomes. Although previous research has established that adherence contracts and orientation to aftercare are an effective method of increasing aftercare attendance, participation levels are often low. We examined whether feedback and prompts are an effective means of further increasing adherence to substance abuse aftercare group therapy beyond that found when orientation and adherence contracts are completed. We randomly assigned 41 substance dependent individuals completing inpatient or intensive outpatient treatment to receive either attendance feedback and prompts to attend aftercare, or no feedback and no prompts. participants who received the feedback and prompts were more likely to begin aftercare, and to attended more weekly aftercare groups, and they were less likely to be readmitted to the hospital. The clinical utility of prompts and feedback are discussed.

Contracting, prompting, and reinforcing substance use disorder continuing care: a randomized clinical trial.

Although continuing care is strongly related to positive treatment outcomes for substance use disorder (SUD), participation rates are low and few effective interventions are available. In a randomized clinical trial with 150 participants (97% men), 75 graduates of a residential Veterans Affairs Medical Center SUD program who received an aftercare contract, attendance prompts, and reinforcers (CPR) were compared to 75 graduates who received standard treatment (STX). Among CPR participants, 55% completed at least 3 months of aftercare, compared to 36% in STX. Similarly, CPR participants remained in treatment longer than those in STX (5.5 vs. 4.4 months). Additionally, CPR participants were more likely to be abstinent compared to STX (57% vs. 37%) after 1 year. The CPR intervention offers a practical means to improve adherence among individuals in SUD treatment.

Implementation of evidence-based substance use disorder continuing care interventions.

Continuing care following initial substance use disorder treatment often is associated with improved treatment outcomes and evidence-based interventions (EBIs) have been developed in this area. However, rates of patient participation in continuing care treatment and mutual help groups (MHGs) are low and a large gap exists between the existing EBIs and actual clinical care. This paper uses the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) to review the literature on continuing care treatment and monitoring, and mutual help-group promotion. Although existing research provides implications for implementing EBIs in continuing care, few direct implementation trials have been conducted. This literature indicates that EBIs in continuing care have been successfully modified for different settings, that they can be delivered using different modalities (e.g., individual, group, and telephone-based care), and that low cost options are available. Additionally, much is known about the differential effectiveness of continuing care with different populations that may guide treatment programs and providers in selecting the most effective interventions for their clients. One significant barrier to successful implementation of EBIs for continuing care is the lack of information about incentives for providing continuing care across what in the CFIR terminology is a programs outer setting (i.e., external economic, political, and social setting), and its inner setting (i.e., internal political, structural, and cultural contexts). Implications for implementation of EBIs in substance use disorder continuing care are discussed.

Social reinforcement of substance abuse aftercare group therapy attendance

Although adherence to aftercare therapy in substance abuse treatment is associated with improved treatment outcome, relatively little research has explored methods of improving aftercare adherence. To improve on established methods of promoting aftercare adherence, 43 graduates of the 28-day intensive substance abuse treatment program at the Salem Veterans Affairs Medical Center who received standard aftercare orientation are compared to 38 graduates who received the standard intervention plus social reinforcement of aftercare group therapy attendance. Clients who received social reinforcement attended more aftercare group sessions than did clients who received the standard treatment during the 8-week intervention (68.8% vs. 49.4% of sessions attended), and during the 4-week follow-up period (41.5% vs. 31.4% of sessions). These findings are noteworthy since the standard treatment had been shown to be effective in increasing aftercare adherence in prior studies (Lash, 1998; Lash & Blosser, 1999). Areas for future research are discussed.

Adherence to substance abuse treatment: Clinical utility of two MMPI-2 scales

In this study, we examined the ability of the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) Addiction Acknowledgment scale (AAS; Weed, Butcher, McKenna, & Ben-Porath, 1992) and Negative Treatment Indicators scale (TRT; Butcher, Graham, Williams, & Ben-Porath, 1990) to predict adherence to and outcomes from substance abuse treatment. There was no evidence that the AAS was related to treatment adherence or outcome in our sample. However, results did reveal a significant positive relation between scores on the TRT scale and readmission to the hospital. Further analyses identified an optimal score for use in similar clinical populations and settings, and characteristics of high and low scorers. Compared to low scorers, high TRT scorers were more likely to not return for treatment after an initial screening interview. If they did return for treatment, high TRT scorers were more likely to experience fewer treatment days and to be rated as having lower motivation, poorer participation, and poorer comprehension of program materials. These findings provide promising initial evidence of the utility of the TRT scale for identifying patients who may be at a high risk for unsuccessful substance abuse treatment.

Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment

Epidemiological data from treatment and community samples of individuals with substance use disorders indicate that the rates of co-occurring psychiatric disorders are high and that these disorders are associated with poor treatment adherence and outcomes. A growing body of research indicates that continuing care adherence interventions positively impact treatment outcome. However, it is unclear whether these interventions are effective for individuals with co-occurring psychiatric disorders. This paper explores this question with data from 150 participants who were randomized to receive a behavioral continuing care adherence intervention involving contracting, prompting and reinforcing attendance (CPR), or standard treatment. Fifty-one percent of the participants had one or more co-occurring Axis I or Axis II psychiatric disorders in addition to a SUD diagnosis. Among individuals with co-occurring disorders, those who received the CPR intervention show increased duration of treatment and improved 1-year abstinence rates compared to those who received STX. Additionally, effects of the CPR intervention were generally more pronounced among persons with co-occurring Axis I and/or Axis II disorders than those without these disorders. Treatment implications are discussed.

Contracting, prompting and reinforcing substance use disorder continuing care

The contracting, prompting and reinforcing (CPR) aftercare intervention has improved treatment adherence and outcomes in a number of clinical trials. In multisite randomized clinical trial 92 graduates of two intensive substance use disorder programs who received CPR were compared to 91 who received standard treatment (STX). The CPR group evidenced increased frequency of aftercare group therapy attendance and near significant findings suggested that more CPR than STX participants completed 3 months (76 vs. 64%), 6 months (48 vs. 35%), and 9 months (35 vs. 22%) of aftercare. However, the groups did not differ on the majority of attendance measures and had similar abstinence rates at the 3-month (67% CPR vs. 71% STX), 6-month (52% CPR vs. 51% STX), and 12-month (the primary outcome measure; 48% CPR vs. 49% STX) follow-up points. Exploratory analyses suggest that CPR might be more effective among participants not required to attend aftercare. The incremental capital and labor cost of CPR compared to STX was

Validity of the Structured Clinical Interview for DSM-IV Among Veterans Seeking Treatment for Substance Use Disorders

98.25 per participant.

Paranoid Personality Disorder in the United States: The Role of Race, Illicit Drug Use, and Income

This paper examines the validity of the Structured Clinic Interview for DSM-IV (SCID) I and II in a sample of Veterans seeking treatment for substance use disorders (SUDs). Participants (N = 183) initially receiving residential or outpatient treatment for SUDs completed the SCID I and II. More than one-third of participants met criteria for an Axis I disorder, and almost one-half met criteria for an Axis II disorder. Concurrent, discriminant, and predictive validity were examined for diagnoses of SUDs and antisocial personality disorder (APD), as well as symptoms of depression, anxiety, and thought disorder. Results generally provided strong support for the concurrent, discriminant, and predictive validity of the SCID I diagnoses of alcohol use disorders (AUDs) and strong support for the concurrent and discriminant validity of drug use disorders (DUDs). There was mixed support for the concurrent validity of APD. Predictive validity for DUDs or APD was not supported.

Pre-Implementation Review of Contracts, Prompts, and Reinforcement in SUD Continuing Care.

Differential rates of schizophrenia and paranoia symptoms have been found for Black and White individuals. Paranoid personality disorder shares symptoms with schizophrenia, yet has received minimal attention with regard to potential racial differences. In a sample consisting of 180 substance use disorder treatment-seeking individuals, the association between the diagnosis of paranoid personality disorder and the variables of race, cannabis use disorder, and income were examined. Results extended previous findings to paranoid personality disorder, supporting the hypothesis that Black individuals would be diagnosed with higher rates of paranoid personality disorder. Cannabis use disorder status and income did not predict paranoid personality disorder diagnoses.