Effects of EAP follow-up on prevention of relapse among substance abuse clients

Telephone-based continuing care counseling in substance abuse treatment: Economic analysis of a randomized trial

PURPOSE

To investigate whether telephone-based continuing care (TEL) is a promising alternative to traditional face-to-face counseling for clients in treatment for substance abuse.

METHODS

Patients with alcohol and/or cocaine dependence who had completed a 4-week intensive outpatient program were randomly assigned through urn randomization into one of three 12-week interventions: standard continuing care (STD), in-person relapse prevention (RP), or telephone-based continuing care (TEL). This study performed cost, cost-effectiveness, and cost-benefit analyses of TEL and RP compared to STD, using results from the randomized clinical trial with two years of follow up (359 participants). In addition, the study examined the potential moderating effect of baseline patient costs on economic outcomes.

RESULTS

The study found that TEL was less expensive per client from the societal perspective ($569) than STD ($870) or RP ($1684). TEL also was also significantly more effective, with an abstinence rate of 57.1% compared to 46.7% for STD (p<0.05). Thus TEL dominated STD, with a highly favorable negative incremental cost-effectiveness ratio (-$1400 per abstinent year). TEL also proved favorable under a benefit-cost perspective.

CONCLUSIONS

TEL proved to be a cost-effective and cost-beneficial contributor to long-term recovery over two years. Because TEL dominated STD care interventions, wider adoption should be considered.

How effective is continuing care for substance use disorders? A meta-analytic review

Given the often chronic nature of substance use disorders, patients sometimes receive less intensive continuing care following an initial period of more intensive treatment. This meta-analysis estimated the effect of continuing care and formally tested several proposed moderators (intervention duration, intensity, modality, and setting) of that effect. A systematic search identified 33 controlled trials of continuing care; 19 included a no/minimal treatment condition and were analyzed to assess the overall effect of continuing care versus control. Continuing care had a small, but significant, positive effect size, both at the end of the continuing care interventions (g=0.187, p<0.001) and at follow-up (g=0.271, p<0.01). Limited by a small number of studies, analyses did not identify any significant moderators of overall effects. These results show that continuing care can provide at least modest benefit after initial treatment. We discuss study characteristics that may have reduced the magnitude of the overall continuing care effect estimate.

Effectiveness of public health programs for decreasing alcohol consumption

Excessive alcohol consumption and the associated negative consequences are a major public health concern in the United States and throughout the world. Historically, there have been numerous attempts to develop policies and prevention programs aimed at decreasing high-risk alcohol use. Policy initiatives have demonstrated considerable effectiveness and include changes in the minimum legal drinking age, reductions in acceptable legal limits for blood alcohol concentration while operating a motor vehicle, as well as decreasing availability and access to alcohol for underage individuals. Primary prevention programs that have used exclusively educational approaches have received mixed results. Increasing effectiveness has been associated with prevention programs that have utilized a multi-component approach and have included educational initiatives with environmental changes.

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.

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.

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

In the field of addiction treatment, the term continuing care has been used to indicate the stage of treatment that follows an initial episode of more intensive care. This article reviews controlled studies of continuing care conducted over the prior 20 years. The results indicate that continuing care interventions were more likely to produce positive treatment effects when they had a longer planned duration, made more active efforts to deliver treatment to patients, and were studied more recently. However, there was considerable variability in patient response and room for improvements in participation rates and effectiveness. It is possible that the effectiveness of continuing care interventions could be further improved by the use of adaptive algorithms, which adjust treatment over time based on changes in patients' symptoms and status. The use of alternative service delivery methods and care settings may also lead to greater engagement and retention in continuing care, particularly among the large numbers of individuals who do not want traditional, clinic-based specialty care.

The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders

AIMS

This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1-3) and longer-term (months 4-9) abstinence.

DESIGN

Two-group randomized design.

SETTING

Eleven counties surrounding a community-based residential treatment program in the Midwestern section of the United States.

PARTICIPANTS

A total of 183 adolescents, ages 12-17 years, with one or more Diagnostic and Statistical Manual version IV (DSM-IV) substance use dependence disorder and met American Society for Addiction Medicine (ASAM) placement criteria for non-medical residential treatment.

INTERVENTION

Prior to discharge from residential treatment, participants were assigned randomly to receive either UCC, available at outpatient clinics in the 11-county study area, or ACC via home visits.

MEASUREMENTS

Self-reported interview data were collected at intake, 3, 6 and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months.

FINDINGS

ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence.

CONCLUSIONS

ACC appears to be an effective alternative to UCC for linking, retaining and increasing adherence to continuing care. Replication with larger samples is needed to investigate further the direct and indirect effects of ACC found in this study

Is there a case for extended interventions for alcohol and drug use disorders?

AIMS

To determine whether there is evidence to support the implementation of extended interventions (i.e. longer than 6 months) for individuals with alcohol or other drug use disorders.

METHODS

Literature on extended behavioral and pharmacotherapy interventions was reviewed, along with findings from studies of extended monitoring and monitoring paired with adjunctive counseling. Studies were identified through database searches, citations in prior reviews and examinations of recent volumes of relevant journals. Key terms were defined, and a theoretical rationale was presented for extended treatment. Several adaptive treatment studies that made use of stepped care or continuation protocols were also described.

MEASUREMENTS

The primary outcomes that were considered were alcohol and drug use during the intervention and post-intervention follow-ups. Other outcomes were examined when they were included in the articles reviewed.

FINDINGS

Most of the studies in the review provided support for the effectiveness of extended interventions for alcohol and drug abusers, whether the extended care was delivered through face-to-face contact or via the telephone. These findings held across all types of interventions that were examined (e.g. behavioral treatment, pharmacotherapy and monitoring). However, only a few studies directly compared extended and standard length version of the same intervention. New developments in addiction treatment with implications for extended care models were also described and discussed.

CONCLUSIONS

The findings of the review indicate that maintaining therapeutic contact for extended periods of time with individuals with alcohol and other drug disorders appears to promote better long-term outcomes than 'treatment as usual', although more studies are needed that compare extended and standard versions of interventions. Achieving good compliance and successful disease management with extended interventions will probably require adaptive protocols in which the intensity of treatment can be adjusted up or down in response to changes in symptoms and functioning over time. Future directions in research on extended interventions were discussed.

The Effectiveness of Telephone-Based Continuing Care in the Clinical Management of Alcohol and Cocaine Use Disorders: 12-Month Outcomes

This study of continuing care for substance dependent patients compared a telephone-based monitoring and brief counseling intervention (TEL) with 2 face-to-face interventions, relapse prevention (RP) and standard 12-step group counseling (STND). The participants were graduates of intensive outpatient programs who had current dependence on alcohol and/or cocaine. Self-report, collateral, and biological measures of alcohol and cocaine use were obtained over a 12-month follow-up. The treatment groups did not differ on abstinence-related outcomes in the complete sample (N = 359) or on cocaine use outcomes in participants with cocaine dependence (n = 268). However, in participants with alcohol dependence only (n = 91), TEL produced better alcohol use outcomes than STND on all measures examined and better outcomes than RP on some of the measures.

Mailed feedback reduces consumption among moderate drinkers who are employed

To test the efficacy of mailed feedback for drinking reduction among employees of a manufacturing firm, 48 drinkers were recruited and alternately assigned to receive mailed feedback on their drinking either immediately or after an 8-week waiting period. Using a delayed treatment design, participants were assessed by mail at baseline, 8, and 16 weeks. After viewing their feedback, participants indicated a higher level of importance of making a change, but not confidence in their ability. There were also significant decreases in consumption after receiving the feedback, and these changes were mediated by participants' increased perceptions regarding the "riskiness" of alcohol consumption. An additional 26 nondrinkers at baseline volunteered to participate and also were mailed feedback. Among this group, receipt of feedback indicating a very low level of risk did not lead to increased drinking. This cost-effective intervention appears to reduce consumption among light-to-moderate drinkers, and may warrant a larger place in the framework of workplace alcohol reduction programs.

The impact of drinking and drinking consequences on short-term employment outcomes in at-risk drinkers in six southern states

Alcohol use and misuse impose economic burdens, with over half the total costs estimated associated with lost productivity. Research on labor productivity and alcohol abuse has been limited by methodologic differences, making conclusions equivocal. This study employed two waves of data from a community probability sample of 658 at-risk drinkers. It analyzed the prospective impact of several measures of drinking and drinking consequences on the 6-month follow-up probability of not being employed and fewer weeks of employment if employed. Drinking seven drinks or more on an average drinking day significantly increased the likelihood of not working and, for those who were working, reduced weeks of employment. Thus, productivity benefits may accrue from developing treatments for at-risk drinkers, particularly interventions to reduce drinking.

The role of continuing care in outpatient alcohol treatment programs

Substance-abusing patients are frequently urged to participate in continuing care, or "after-care," following an initial phase of treatment. However, there has been relatively little research on the effectiveness of continuing care, particularly in the context of outpatient service delivery systems. Since 1988, 12 controlled studies of continuing care for alcohol use disorders have been published. Only three of these studies were conducted exclusively within outpatient service delivery systems; in the other studies, all patients (six studies) or at least half of the patients (three studies) were first treated in inpatient or residential facilities. Four of the 12 studies yielded positive findings (two of six studies with minimal/no continuing care control conditions and two of six studies with active control conditions). It is suggested that continuing care treatment might be improved by placing greater emphasis on addressing co-occurring problems and facilitating the identification and strengthening of patients' skills, interests, and talents, although additional research would be needed to evaluate the impact of these modifications. Further research is also needed to establish guidelines for when patients are ready to enter continuing care and to develop performance indicators to monitor progress.

Effectiveness of continuing care interventions for substance abusers. Implications for the study of long-term treatment effects

Substance-abusing patients are frequently urged to participate in lower intensity continuing care interventions, also known as "stepdown care" or "aftercare," following an initial phase of treatment. Since 1988, 15 controlled studies of continuing care for alcohol or drug abuse have been published, with follow-up data on substance use presented in 14 of these studies. In the studies that featured an active control condition, only 1 of 7 yielded positive findings. In the studies that featured a minimal- or no-treatment control, 3 of 7 studies yielded positive findings. The relative paucity of continuing care studies, coupled with the lack of stronger evidence of clinical effectiveness, provides a convincing rationale for conducting evaluations of continuing interventions, as well as evaluations of combinations of various primary and continuing interventions. Methodological issues in the evaluation of continuing care and potential research questions that could be addressed in long-term follow-up studies are outlined and discussed.

Evaluation of a workplace brief intervention for excessive alcohol consumption: the workscreen project

BACKGROUND

The workplace provides a useful setting for early identification and intervention with individuals who have unhealthy lifestyles. The objective was to evaluate the effects of a workplace-based lifestyle intervention (Workscreen) to reduce excessive drinking.

METHOD

There were eight Australia Post networks randomly allocated to experimental and control conditions, comprising 67 worksites and 1206 employees. The experimental condition involved a broad spectrum lifestyle campaign, incorporating support from management, employee awareness of health, and brief interventions for high-risk behaviors, including excessive alcohol use. Focus groups identified relevant cultural factors. Changes in workplace culture and employee behavior were assessed 10 months after baseline. Males and females were analyzed separately.

RESULTS

Over half of APOST employees participated at each screening point. In the experimental condition 61% of employees overall and 58% of those identified as excessive drinkers in Phase 1 responded to the lifestyle campaign by attending health assessments. Analyses focusing on the organization as a whole did not reveal significant reductions in excessive alcohol consumption among men or women. However, a significant reduction in number of drinks was observed in the experimental condition among women for whom completion of baseline and follow-up could be confirmed (P < 0.001).

CONCLUSIONS

The present study indicates that a workplace-based lifestyle campaign can assist self-selected employees in reducing their alcohol consumption. There was a moderately high level of participation among those identified as drinking excessively, which supports our approach of embedding a low-intensity alcohol program within the context of a broader health promotion campaign.

A preliminary evaluation of the effectiveness of a standardized Student Assistance Program

We examined the effectiveness of Student Assistance Program group counseling. One hundred and forty-four (144) substance using high school seniors completed a questionnaire in 1995 concerning their substance use before and after counseling, their experience in counseling, and the impact of counseling on their substance use. Participants reported significant decreases in substance use and attributed these changes to counseling. Most participants liked counseling, and higher frequency drinkers did not differ from lower frequency drinkers in liking counseling and reporting decreased substance use. These results offer support for the effectiveness of such interventions and highlight the need for additional research in the area.

Optimizing the cost-effectiveness of alcohol treatment: a rationale for extended case monitoring

There has been much research on and debate about the appropriate length of acute treatment for alcohol problems. In the United States, the lengthy and costly treatment programs of only a few years ago have been supplanted by ever-shorter and less intensive protocols, with little evidence that this trend will end soon. In this paper, we argue that, because of the chronic, recurrent nature of alcohol problems, an optimal system for delivering treatment services to alcoholics needs to focus on long-term engagement with clients. There is evidence from studies on research reactivity and telephone follow-up protocols that a low-intensity long-term protocol for maintaining contact with clients over time spans measured in years may result in better long-term clinical outcomes and reduced long-term health care utilization and costs. We describe a flexible long-term low-intensity follow-up protocol for alcohol abusers we call "case monitoring." This protocol is specifically designed to minimize long-term health-care use. We predict that such an intervention should be especially efficacious for women, persons with comorbid Axis I disorders, and persons lower in sociopathy. The design of a study to determine the clinical and health service effects of this intervention is also described.

Alcohol: a review of the impact of worksite interventions on health and behavioral outcomes

PURPOSE

To review, evaluate, and summarize research published in scientific journals linking alcohol-related interventions in the worksite to either individual or organizational outcomes.

METHODS

A review of the literature published in peer-review journals between 1970 and 1995 identified 24 articles that reported the results of studies on the impact of worksite programs on alcohol control on health and behavioral outcomes.

IMPORTANT FINDINGS

There is strong suggestive evidence and some conclusive evidence that worksite interventions including core components of employee assistance programs are effective in rehabilitating employees with alcohol problems. There is suggestive and conclusive evidence that worksite training oriented toward alcohol problems affects the attitudes of supervisors and employees for reasonable periods after the completion of training.

CONCLUSIONS

Investment in worksite interventions directed at reducing alcohol-related problems appears to be a sound strategy, although considerably more research is needed. This research should include broad representation of appropriate worksite populations. Similar measurements should be used across studies. To the extent possible, randomized control group designs should be employed. Without significant external sponsorship, it is not likely that such an improved body of research data will emerge.

Occupational stress and the risk of alcohol abuse and dependence

Using prospective data, we examined the relationship between occupational stress and risk for alcohol disorders. Consistent with the Demand/Control model for psychosocial work environments, we hypothesized that individuals working in high-strain occupations (jobs with high demands and low control) would be at increased risk for alcohol abuse-dependence relative to those in low-strain occupations (jobs with low demands and high control). We classified high occupational strain into two categories: (1) jobs with high psychological demands and low control, and (2) those with high physical demands and low control. A total of 18,571 study subjects were selected in 1980-1984 by taking probability samples of adult household residents at five sites of the Epidemiologic Catchment Area Program. At baseline, participants completed standardized interviews that measured sociodemographic variables and assessed whether they had met diagnostic criteria for currently or formerly active alcohol abuse-dependence syndromes. The interviews were readministered 1 year later to identify cases among the participants. Subjects were sorted into risk sets by age and residence census tract, and persons with a previous history of alcohol abuse or dependence, as well as those who were over 64 years or had no history of full-time employment, were excluded. Among the 507 participants included in the risk sets, there were 126 incident cases of alcohol abuse-dependence and 381 age and residence-matched noncases.(ABSTRACT TRUNCATED AT 250 WORDS)

A Methodology for Evaluating the Costs and Benefits of Employee Assistance Programs

Employee assistance programs (MPs) represent a relatively new fringe benefit for workers; the number of these programs has been steadily increasing in worksites of all sizes. Despite this surge in the growth of EAPs, few studies have estimated their costs or benefits. To guide future economic evaluation studies of EAPs, we have developed a methodology that has four components: a process description to understand the structure, operating environment, and goals of the EAP; a cost analysis to comprehensively identify and estimate the full range of EAP costs; an outcomes analysis to rigorously estimate the effectiveness of the EAP for groups of employees and the overall impact of the EAP on employee performance and workplace productivity; and an economic evaluation to estimate cost-effectiveness ratios, dollar benefits, and net benefits of the EAP. Our methodology is based on standard economic theory, but we present the evaluation strategy in a nontechnical way so that it can be used by employers and other researchers to estimate the costs and benefits of EAPs.