Continuing care research: what we have learned and where we are going

Evolution of concept, but not action, in addiction treatment

The Western approach to addiction treatment involves a medical or disease orientation to understanding the onset, course, and management of addiction, and a clinical goal of abstinence or very significant reductions in drug use, usually with a combination of behavioral and pharmacological interventions. Even within this Western approach, and despite several consensually accepted features of addiction, a significant mismatch remains between what this culture has come to accept as the nature of the disease and how that same culture continues to treat the disease. This paper discusses the evolution of these Western concepts over the past decade without a corresponding evolution in the nature, duration, or evaluation standards for addiction treatment. (1) Here, we take the position that continuing care and adaptive treatment protocols, combining behavioral therapies, family and social supports, and, where needed, medications show much promise to address the typically chronic, relapsing, and heterogeneous nature of most cases of serious addiction. By extension, methods to evaluate effectiveness of addiction treatment should focus upon the functional status of patients during the course of their treatment instead of post-treatment, as is the evaluation practice used with most other chronic illnesses.

Pilot trial of a recovery management intervention for heroin addicts released from compulsory rehabilitation in China

China faces the challenge of dual epidemics of drug use and HIV/AIDS. Despite the high relapse rate among heroin addicts released from compulsory rehabilitation facilities, there are few programs available in China to assist these addicts in the community. We pilot-tested in China a Recovery Management Intervention (RMI) program designed to facilitate early detection of relapse and prompt linkage from compulsory rehabilitation to the community and, if participants relapse, to community-based methadone maintenance treatment (MMT) programs. One hundred heroin addicts were randomly assigned to either the Standard Care group (n = 50) or the RMI group (n = 50). At the end of the 3-month trial, participants in the RMI group, relative to the standard care group, demonstrated positive outcomes in recidivism due to relapse (0 vs. 6%, p = .08; d = 0.354), MMT participation (8% vs. 0, p = 0.06; d = 0.417), and employment (33% vs. 2%, p < .001; d = 0.876), although no difference was found in urine testing results (8.5% vs. 8.7%; d = 0.013) among interviewed participants. These pilot study results were based on a small sample size and short-term observation, suggesting the need for more research to further improve and test RMI effectiveness with larger samples over a longer period of time in order to provide evidence in support of RMI as an effective strategy for community reintegration among addicts released from rehabilitation facilities in China.

Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model

OBJECTIVES

How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry.

METHODS

In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure.

RESULTS

A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without.

CONCLUSIONS

Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.

Motivation for treatment among women offenders in prison-based treatment and longitudinal outcomes among those who participate in community aftercare

Participation in aftercare may reduce risk of recidivism among women offenders with substance use problems following their release to the community. This study examines motivation to participate in aftercare among women offenders and whether their participation in both in-custody and aftercare treatment reduces their risk of recidivism. Surveys were conducted with women (N = 1,158) in prison-based substance abuse treatment programs. Return-to-prison was examined among participants in community-based aftercare (N = 1,182) over 12 months following treatment discharge. Higher treatment motivation was associated with child welfare involvement, prior treatment, and use of "harder" drugs; ethnic minority women had lower treatment motivation compared with White women. Participants who completed the aftercare program, or who had longer treatment duration, and those who had participated in an in-prison program prior to parole had reduced risk of recidivism. Study findings suggest the value of community aftercare for women offenders, particularly when combined with prior in-prison treatment.

A "SMART" design for building individualized treatment sequences

Interventions often involve a sequence of decisions. For example, clinicians frequently adapt the intervention to an individual's outcomes. Altering the intensity and type of intervention over time is crucial for many reasons, such as to obtain improvement if the individual is not responding or to reduce costs and burden when intensive treatment is no longer necessary. Adaptive interventions utilize individual variables (severity, preferences) to adapt the intervention and then dynamically utilize individual outcomes (response to treatment, adherence) to readapt the intervention. The Sequential Multiple Assignment Randomized Trial (SMART) provides high-quality data that can be used to construct adaptive interventions. We review the SMART and highlight its advantages in constructing and revising adaptive interventions as compared to alternative experimental designs. Selected examples of SMART studies are described and compared. A data analysis method is provided and illustrated using data from the Extending Treatment Effectiveness of Naltrexone SMART study.

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 program's 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.

Driving while intoxicated among individuals initially untreated for alcohol use disorders: one- and sixteen-year follow-ups

OBJECTIVE

This study examined associations between frequency of driving while intoxicated (DWI) at baseline and obtaining alcohol-related help at follow-up, and between obtaining help and subsequent reductions in DWI. It also examined improvements on personal functioning and life context indices as mediators between obtaining help and reduced occurrences of DWI.

METHOD

A total of 628 individuals who were initially untreated for alcohol use problems completed a baseline inventory; follow-ups were 1, 3, and 16 years later.

RESULTS

More extended participation in outpatient treatment and Alcoholics Anonymous (AA) during Year 1 was associated with a lower likelihood of DWI at the 1-year follow-up. More extended participation in AA through Year 3 was associated with a lower likelihood of DWI at the 16-year follow-up. Improvement on personal functioning and life context indices was associated with reduced risk of subsequent occurrences of DWI. Decreases in drinking-related problems, impulsivity, and drinking to reduce tension mediated associations between more AA participation and reductions in DWI at 1 year.

CONCLUSIONS

Among initially untreated individuals, sustained mutual help may be associated with a reduced number of occurrences of DWI via fewer drinking consequences and improved psychological functioning and coping. Treatment providers should attend to these concomitants of DWI and consider actively referring individuals to AA to ensure ongoing AA affiliation.

Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model

OBJECTIVES

How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry.

METHODS

In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure.

RESULTS

A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without.

CONCLUSIONS

Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.

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.

Computerized continuing care support for alcohol and drug dependence: a preliminary analysis of usage and outcomes

The central aim of this administrative data analysis was to examine usage of a Web-based disease management program designed to provide continuing recovery support to patients discharged from residential drug and alcohol treatment. Tailored clinical content was delivered in a multimedia format over the course of 18 months posttreatment. The program also included access to a recovery coach across the 18 months. Consistent with other disease management programs, program usage decreased over time. A small subsample of patients accessed a large number of program modules in the year following treatment; these patients had significantly higher abstinence rates and consumed less alcohol than patients accessing few or no modules. Regression analyses revealed a significant relationship between the number of modules accessed and substance use outcomes in the year following treatment when controlling for motivation, self-efficacy, and pretreatment substance use. Limiting the analyses to only the more compliant patients did not reduce the magnitude of these effects. These preliminary results suggest that computerized support programs may be beneficial to patients recently treated for drug and alcohol issues. Methods to increase program engagement need additional study.

Why health care process performance measures can have different relationships to outcomes for patients and hospitals: understanding the ecological fallacy

Relationships between health care process performance measures (PPMs) and outcomes can differ in magnitude and even direction for patients versus higher level units (e.g., health care facilities). Such discrepancies can arise because facility-level relationships ignore PPM-outcome relationships for patients within facilities, may have different confounders than patient-level PPM-outcome relationships, and may reflect facility effect modification of patient PPM-outcome relationships. If a patient-level PPM is related to better patient outcomes, that care process should be encouraged. However, the finding in a multilevel analysis that the proportion of patients receiving PPM care across facilities nevertheless is linked to poor hospital outcomes would suggest that interventions targeting the health care facility also are needed.

Initiation and engagement in chronic disease management care for substance dependence

BACKGROUND

Substance dependence treatment is often episodic and not well coordinated with healthcare for common comorbidities. Chronic disease/care management (CDM), longitudinal, patient-centered care delivered by multidisciplinary health professionals, may be well suited to treat substance dependence (SD).

OBJECTIVE

To examine initiation and engagement with CDM care for SD located in a primary medical setting.

METHODS

We prospectively studied substance dependent participants enrolled in a trial of CDM addiction care. Primary study outcomes, based upon Washington Circle performance measures, were 14-day initiation of CDM care and 30-day engagement with CDM care. Factors associated with these outcomes were determined using multivariable logistic regression models. We also estimated the proportion of participants who eventually attended at least two visits and four visits by the end of the study (Kaplan-Meier method).

RESULTS

Of 282 participants, approximately half of the cohort (45%, 95% Confidence Interval [CI] 39-51%) met criteria for 14-day initiation and 23% (95% CI 18-28%) for 30-day engagement with CDM care. Most participants attended two or more (81%, 95% CI 76-85%) and four or more CDM visits (62%, 95% CI 56-68%). Major depressive episode (AOR 2.60, 95% CI 1.39, 4.87) was associated with higher odds of 14-day initiation; younger age, female sex, and higher alcohol addiction severity were associated with lower odds of 30-day engagement with CDM care.

CONCLUSION

People with SD appear to be willing to initiate and engage with CDM care in a primary medical care setting. CDM care has the potential to improve the quality of care for people with addictions.

Redefining retention: recovery from the patient's perspective

This study examines the process of discharge and treatment reentry for six participants who entered treatment voluntarily but were administratively discharged from methadone treatment programs. The participants completed semistructured interviews at treatment entry and at four, eight and 12 months post-treatment entry. Grounded theory methodology was used to examine the phenomenon of treatment reentry from the perspective of the patients, who often viewed their recovery as an accumulation of positive changes. Differences in terms of the patients' goals and motivations for seeking treatment from those of the treatment programs, combined with difficulties encountered during the treatment process eventually led to discharge. However, these patients were then able to navigate their way through the treatment system in different ways in order to remain in treatment. The authors conclude that failure to abide by treatment clinic rules do not necessary constitute "treatment failure" from the perspective of patients, who often wish to remain in treatment even if it is not progressing optimally from the program's perspective. As a result, the recovery process can be more fragmented and is often characterized by a series of cyclical treatment episodes rather than continuous time in treatment, thereby impeding their progress towards recovery.

Voucher incentives increase treatment participation in telephone-based continuing care for cocaine dependence

BACKGROUND

Telephone-based monitoring is a promising approach to continuing care of substance use disorders, but patients often do not engage or participate enough to benefit. Voucher incentives can increase retention in outpatient treatment and continuing care, but may be less effective when reinforcement is delayed, as in telephone-based care. We compared treatment utilization rates among cocaine-dependent patients enrolled in telephone continuing care with and without voucher incentives to determine whether incentives increase participation in telephone-based care.

METHOD

Participants were 195 cocaine-dependent patients who completed two weeks of community-based intensive outpatient treatment for substance use disorders and were randomly assigned to receive telephone continuing care with or without voucher incentives for participation as part of a larger clinical trial. The 12-month intervention included 2 in-person orientation sessions followed by up to 30 telephone sessions. Incentivized patients could receive up to $400 worth of gift cards.

RESULTS

Patients who received incentives were not more likely to complete their initial orientation to continuing care. Incentivized patients who completed orientation completed 67% of possible continuing care sessions, as compared to 39% among non-incentivized patients who completed orientation. Among all patients randomized to receive incentives, the average number of completed sessions was 15.5, versus 7.2 for patients who did not receive incentives, and average voucher earnings were $200.

CONCLUSIONS

Voucher incentives can have a large effect on telephone continuing care participation, even when reinforcement is delayed. Further research will determine whether increased participation leads to better outcome among patients who received incentives.

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.

Randomized trial of enhanced profiling in substance abuse treatment

A randomized trial of substance abuse treatment programs tested whether "enhanced profiles," consisting of feedback and coaching about performance indicators, improved the performance of residential, methadone, and detoxification programs. These enhanced profiles were reviewed during quarterly on-site visits between October 2005 and July 2007. The performance indicators were the percentage of clients completing referrals to a lower level of care, and the percentage of clients admitted to a higher level of care within 30 days of discharge. Control programs received only "basic profiles," consisting of emailed quarterly printouts of these performance indicators. Effectiveness was evaluated using hierarchical linear models with client-level information nested within agencies and regions of the state. Treatment programs receiving enhanced profiles (n = 74) did not perform significantly differently from those receiving only basic profiles (n = 29) on either performance measure. To improve performance, interventions with greater scope and incentives may be needed.

Lessons from five states: public sector use of the Washington Circle performance measures

Five states (Connecticut, Massachusetts, New York, North Carolina, and Oklahoma) have incorporated the Washington Circle (WC) substance abuse performance measures in various ways into their quality improvement strategies. In this article, we focus on what other states and local providers might learn from these states' experiences as they consider using WC performance measures. Using a case study approach, we report that the use of WC measures differs across these five states, although there are important common themes required for adoption and sustainability of performance measures, which include leadership, evaluation of specification and use of measures over time, state-specific adaptation of the WC measure specifications, collaboration with consultants and partners, inclusion of WC measures in the context of other initiatives, reporting to providers and the public, and data and resource requirements. As additional states adopt some of the WC measures, or adopt other performance measurement approaches, these states' experiences could help them to develop implementations based on their particular needs.

Treating alcoholism as a chronic disease: approaches to long-term continuing care

For many patients, alcohol and other drug (AOD) use disorders are chronic, recurring conditions involving multiple cycles of treatment, abstinence, and relapse. To disrupt this cycle, treatment can include continuing care to reduce the risk of relapse. The most commonly used treatment approach is initial intensive inpatient or outpatient care based on 12-step principles, followed by continuing care involving self-help groups, 12-step group counseling, or individual therapy. Although these programs can be effective, many patients drop out of initial treatment or do not complete continuing care. Thus, researchers and clinicians have begun to develop alternative approaches to enhance treatment retention in both initial and continuing care. One focus of these efforts has been the design of extended treatment models. These approaches increasingly blur the distinction between initial and continuing care and aim to prolong treatment participation by providing a continuum of care. Other researchers have focused on developing alternative treatment strategies (e.g., telephone-based interventions) that go beyond traditional settings and adaptive treatment algorithms that may improve outcomes for clients who do not respond well to traditional approaches.

An e-health solution for people with alcohol problems

Self-management of chronic diseases has been a research focus for years. Information and communication technologies (ICTs) have played a significant role in aiding patients and their families with that management task. The recent dramatic increase in smartphone capabilities has expanded the potential of these technologies by facilitating the integration of features specific to cell phones with advanced capabilities that extend the reach of what type of information can be assessed and which services can be provided. A recent review of the literature covering the use of ICTs in managing chronic diseases, including addiction, has examined the effectiveness of ICTs, with an emphasis on technologies tested in randomized controlled trials. One example of an addiction-relapse prevention system currently being tested is the Alcohol Comprehensive Health Enhancement Support System (A-CHESS) Program.

Improving access to hard-to-reach services: a soft entry approach to drug and alcohol services for rural Australian Aboriginal communities

Australian Aboriginal communities are concerned about drug- and alcohol-related harms in their communities. There are a significantly higher proportion of substance problems experienced by Aboriginal Australians than non-Indigenous Australians. Ways to address these problems are limited by racial barriers to mainstream services, especially in the rural context. Soft entry was an approach designed to increase Aboriginal Australians' access to Drug & Alcohol (D&A) services. The approach was designed to put control over when and how D&A interventions were delivered in the hands of the community and individuals within it by giving them ready access to a human services worker with specialist knowledge. Quantitative and qualitative evaluation methods found that soft entry substantially increased the number of Aboriginal and non-Aboriginal women accessing drug and alcohol services. It fundamentally shifted the power relationship between counselors and community, providing opportunities to develop a non-stigmatizing trustful rapport to facilitate discussion of harmful substance use. The challenges for drug and alcohol counselors were the slow unpredictability of the approach and the need for highly skilled and responsive communication techniques. However, the factor most likely to improve access to services, once trust is developed, is regular and frequent attendance at the service delivery site.

Inpatient hospitalization in addiction treatment for patients with a history of suicide attempt: a case of support for treatment performance measures

This study attempts to validate substance use disorder (SUD) treatment performance measures (PM) in a naturalistic treatment setting. Despite its significance in healthcare systems and in SUD populations, suicidality is one patient characteristic that remains unexplored in the context of SUD PMs. The current study focused on the extent to which the care processes encouraged by SUD PMs were associated with improved outcomes in patients with a prior suicide attempt as compared to those without. We abstracted Addiction Severity Index and health services data from the VA medical record for 381 veterans who initiated outpatient SUD treatment and completed baseline intake measures at a Midwestern VA hospital. Cox proportional hazard regressions examined how baseline characteristics, prior suicide attempts, and PM status predicted the time until hospitalization for psychiatric or substance use problems. Prior suicide attempts significantly interacted with treatment engagement, and hospitalization risk was significantly higher among individuals with a prior suicide attempt who did not meet PMs. This study provides initial observational evidence that past suicide attempts may be a factor that should be considered when defining performance standards that influence the processes of SUD treatment. Future research on PMs should take into account the differences on indicators of high risk and poor treatment outcomes.

Intervention taxonomy (ITAX): describing essential features of interventions

OBJECTIVES

To identify key features of interventions that need to be considered in the design, execution, and reporting of interventions.

METHODS

Based on prior work on decomposing psychosocial and clinical interventions, current guidelines for describing interventions, and a review of a broad range of intervention studies, we developed a comprehensive intervention taxonomy.

RESULTS

Specific recommendations, rationales, and definitions of intervention delivery and content characteristics including mode, materials, location, schedule, scripting, and sensitivity to participant characteristics, interventionist characteristics, adaptability, implementation, content strategies, and mechanisms of action are provided.

CONCLUSIONS

Applying this taxonomy will advance intervention science by (a) improving intervention designs, (b) enhancing replication and follow-up of intervention studies, (c) facilitating systematic exploration of the efficacy and effectiveness of intervention components through cross-study analysis, and (d) informing decisions about the feasibility of implementation in broader community settings.

Matching motivation enhancement treatment to client motivation: re-examining the Project MATCH motivation matching hypothesis

AIMS

The current study was designed to re-examine the motivation matching hypothesis from Project MATCH using growth mixture modeling, an analytical technique that models variation in individual drinking patterns.

DESIGN, SETTING AND PARTICIPANTS

Secondary data analyses of data from Project MATCH (n = 1726), a large multi-site alcoholism treatment-matching study.

MEASUREMENTS

Percentage of drinking days was the primary outcome measure, assessed from 1 month to 12 months following treatment. Treatment assignment, alcohol dependence symptoms and baseline percentage of drinking days were included as covariates.

FINDINGS

The results provided support for the motivation matching hypothesis in the out-patient sample and among females in the aftercare sample: the majority of individuals with lower baseline motivation had better outcomes if assigned to motivation enhancement treatment (MET) compared to those assigned to cognitive behavioral treatment (CBT). In the aftercare sample there was a moderating effect of gender and alcohol dependence severity, whereby males with lower baseline motivation and greater alcohol dependence drank more frequently if assigned to MET compared to those assigned to CBT.

CONCLUSIONS

Results from the current study lend partial support to the motivation-matching hypothesis and also demonstrated the importance of moderating influences on treatment matching effectiveness. Based upon these findings, individuals with low baseline motivation in out-patient settings and males with low levels of alcohol dependence or females in aftercare settings may benefit more from motivational enhancement techniques than from cognitive-behavioral techniques.

Adolescent outpatient treatment and continuing care: main findings from a randomized clinical trial

This study evaluated the effectiveness and cost-effectiveness of two types of outpatient treatment with and without Assertive Continuing Care (ACC) for 320 adolescents with substance use disorders. Study participants were randomly assigned to one of four conditions: (a) Chestnut's Bloomington Outpatient Treatment (CBOP) without ACC; (b) CBOP with ACC; (c) Motivational Enhancement Therapy/Cognitive Behavior Therapy-7 session model (MET/CBT7) without ACC; and (d) MET/CBT7 with ACC. All study conditions attained high rates of participant engagement and retention. Follow-up interviews were completed with over 90% of the adolescents at three, six, nine, and 12 months after treatment admission. There was a significant time by condition effect over 12 months, with CBOP having a slight advantage for average percentage of days abstinent. Unlike previous findings that ACC provided incremental effectiveness following residential treatment, there were no statistically significant findings with regard to the incremental effectiveness of ACC following outpatient treatment. Analysis of the costs of each intervention combined with its outcomes revealed that the most cost-effective condition was MET/CBT7 without ACC.

Predictors of longitudinal substance use and mental health outcomes for patients in two integrated service delivery systems

AIM

Individuals who have both substance use disorders and mental health problems have poorer treatment outcomes. This study examines the relationship of service utilization and 12-step participation to outcomes at 1 and 5 years for patients treated in one of two integrated service delivery systems: the Department of Veterans Affairs (VA) system and a health maintenance organization (HMO).

METHODS

Sub-samples from each system were selected using multiple criteria indicating severity of mental health problems at admission to substance use disorder treatment (VA=401; HMO=331). Separate and multiple group structural equation model analyses used baseline characteristics, service use, and 12-step participation as predictors of substance use and mental health outcomes at 1 and 5 years following admission.

RESULTS

Substance use and related problems showed stability across time, however, these relationships were stronger among VA patients. More continuing care substance use outpatient visits were associated with reductions in mental health symptoms in both groups, whereas receipt of outpatient mental health services was associated with more severe psychological symptoms. Participation in 12-step groups had a stronger effect on reducing cocaine use among VA patients, whereas it had a stronger effect on reducing alcohol use among HMO patients. More outpatient psychological services had a stronger effect on reducing alcohol use among HMO patients.

CONCLUSION

Common findings across these two systems demonstrate the persistence of substance use and related psychological problems, but also show that continuing care services and participation in 12-step groups are associated with better outcomes in both systems.

Developing and validating process measures of health care quality: an application to alcohol use disorder treatment

BACKGROUND

Health care process quality measures usually are designed by expert panels attempting to synthesize nuanced clinical evidence and subsequently operationalized using administrative data. Many quality measures are then adopted without directly validating their presumed links with outcomes. Later efforts to validate process measures often yield negative results, leaving policy makers without a defensible means of measuring quality. This article presents an alternative strategy for developing and validating process quality measures. The development of an alcohol use disorder (AUD) treatment quality measure is used as an example.

METHODS

An expert panel generated a range of candidate process quality measures of AUD treatment derivable from administrative data that were then tested to determine which had the strongest associations with facility- and patient-level outcomes. Outcome and process data were from 2701 US Veterans Health Administration patients starting a new episode of care at 54 VA facilities.

RESULTS

Several of the candidate process-of-care quality measures predicted facility- and patient-level outcomes. Having at least 3 visits during the first month of specialty AUD treatment was correlated with improvement on the Addiction Severity Index Alcohol composite at the facility level, r = 0.41 (95% Confidence Interval 0.16-0.61), and at the patient level, r = 0.07 (CI: 0.03-0.11).

CONCLUSIONS

These "prevalidated" quality measures can now be judged for the extent they map onto the extant clinical literature and other design requirements. The development and validation strategy we describe should aid in efficiently producing quality measures in other areas of health care.

The Washington Circle continuity of care performance measure: predictive validity with adolescents discharged from residential treatment

This study examined the predictive validity of the Washington Circle (WC) continuity of care after long-term residential treatment performance measure, as well as the impact of assertive continuing care interventions on achieving continuity of care. This measure is a process measure that focuses on timely delivery of a minimal floor of services that are necessary to provide sufficient quality of treatment but should not be construed to be the optimal continuity of care after residential treatment for any specific adolescent. Participants included 342 adolescents who were admitted to long-term residential treatment and randomly assigned to either standard continuing care or an assertive continuing care condition. Overall, results provide initial support for the WC continuity of care after residential treatment performance measure as a useful predictor of 3-month recovery status. In addition, assignment to an assertive continuing care condition was found to significantly increase the likelihood of achieving continuity of care.

Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users

AIMS

Post-discharge monitoring and early reintervention have become standard practice when managing numerous chronic conditions. These two experiments tested the effectiveness of recovery management checkup (RMC) protocols for adult chronic substance users.

INTERVENTION

RMC included quarterly monitoring; motivational interviewing to provide personalized feedback and to resolve ambivalence about substance use; treatment linkage, engagement and retention protocols to increase the amount of treatment received.

PARTICIPANTS AND SETTING

Recruited from sequential addiction treatment admissions, participants in the two experiments were, on average, 36 and 38 years of age, mainly female (59% versus 46%), African American (85% versus 80%) and met past-year criteria for dependence (87% versus 76%).

DESIGN

Participants in both experiments were assigned randomly to the RMC or control condition and interviewed quarterly for 2 years.

MEASUREMENT

The Global Appraisal of Individual Needs (GAIN) was the main assessment instrument.

FINDINGS

RMC participant outcomes were better than control participants in both experiments. Effect sizes were larger in the second experiment in terms of reducing days to readmission (Cohen's d = 0.41 versus d = 0.22), successive quarters in the community using substances (d = -0.32 versus -0.19), past-month symptoms of abuse/dependence (d = -0.23 versus -0.02) and increasing the days of abstinence over 2 years (d = +0.29 versus 0.04).

CONCLUSION

RMC, which provided ongoing monitoring and linkage, is feasible to conduct and is effective for adults with chronic substance dependence.