Alcohol Abuse, Alcoholism, Substance Abuse, Substance Dependence, Substance Use Disorders
Conditions
Keywords
Compliance, Aftercare, Reinforcement, social, Alcoholics Anonymous, Support Groups, Treatment Outcome
Brief summary
The Contracts, Prompts, and Social Reinforcement (CPR) intervention was designed to address the continuing care adherence needs of veterans presenting for substance use disorder (SUD) treatment. Final results of our recently completed HSR&D clinical trial suggest CPR meaningfully impacts aftercare adherence and abstinence rates. However, CPR did not impact abstinence rates at earlier follow-up points, other important measures of treatment outcome, or AA/NA support group attendance. Furthermore, the generalizability of CPR to other sites has not been established. Thus, the intervention has been modified and pilot testing of this improved version of CPR, which includes contingent reinforcement of abstinence and improved prompting of AA/NA attendance (CPR+), shows promising results. We are conducting a multi-site randomized clinical trial to examine the effectiveness of CPR+. We recruited 183 veterans seeking residential treatment at the Salem and Jackson VAMCs. Our primary hypothesis is that the CPR group will have higher 1-year abstinence rates compared to the STX group. Our secondary hypotheses are that the CPR will be particularly effective for individuals with co-morbid psychiatric disorders, and that the CPR+ group will remain in AA/NA and in aftercare for a longer duration, have fewer days of substance use, fewer hospitalizations, and lower costs of care. Treatment outcome will be measured 3-, 6-, and 12-months after participants enter treatment and compared to baseline levels. The current study will seek to extend past findings to show longer-term effectiveness of the CPR+ intervention on continuing care adherence and greater impact on treatment outcome. Dissemination and implementation efforts will be ongoing for this brief, inexpensive intervention, which offers an important means to improve participation and outcome for individuals seeking SUD treatment within the VAMC. Data collection and analysis has been completed.
Detailed description
The Contracts, Prompts, and Social Reinforcement (CPR) intervention was designed to address the continuing care adherence needs of veterans presenting for substance use disorder (SUD) treatment. Final results of our recently completed HSR&D clinical trial suggest CPR meaningfully impacts aftercare adherence and abstinence rates. Among CPR participants, 55% met the VA's SUD continuity of care performance measure (attending at least 2 therapy sessions each month for 3 months), compared to 36% of those in standard treatment (STX). On the primary outcome variable, 57% of the participants in the CPR condition were abstinent at the 1-year follow-up compared to 37% of those in STX. Post hoc moderator analyses also indicate that the intervention was particularly effective for participants with co-morbid psychiatric disorders. However, CPR did not impact abstinence rates at earlier follow-up points, other important measures of treatment outcome, or AA/NA support group attendance. Furthermore, the generalizability of CPR to other sites has not been established. Thus, the intervention has been modified and pilot testing of this improved version of CPR, which includes contingent reinforcement of abstinence and improved prompting of AA/NA attendance (CPR+), shows promising results. We conducted a multi-site randomized clinical trial to examine the effectiveness of CPR+ with 2 specific goals: 1) to compare CPR+ to STX on adherence to continuing care (i.e., AA/NA participation and aftercare therapy) and 2) to assess its effect on treatment outcome. We recruited 183 veterans seeking residential treatment at the Salem and Jackson VAMCs. Our primary hypothesis is that the CPR group will have higher 1-year abstinence rates compared to the STX group. Our secondary hypotheses are that the CPR will be particularly effective for individuals with co-morbid psychiatric disorders, and that the CPR+ group will remain in AA/NA and in aftercare for a longer duration, have fewer days of substance use, fewer hospitalizations, and lower costs of care. Treatment outcome will be measured 3-, 6-, and 12-months after participants enter treatment and compared to baseline levels using the Form-90 Interview, the Addiction Severity Index (ASI), questionnaire responses, and substance use screens. Treatment adherence will be measured using VA databases, medical records, therapist ratings, and questionnaire responses. Abstinence rates will be analyzed using a logistic regression model in which the parameters of interest are estimated using Generalized Estimating Equations. Secondary outcomes will be analyzed using both marginal and linear mixed-effects models as appropriate. The current study sought to extend past findings to show longer-term effectiveness of the CPR+ intervention on continuing care adherence and greater impact on treatment outcome. Dissemination and implementation efforts are ongoing for this brief, inexpensive intervention, which offers an important means to improve participation and outcome for individuals seeking SUD treatment within the VAMC.
Interventions
BEHAVIORALContracting, Prompting and Reinforcement arm
Contracting, prompting and reinforcement of continuing care and abstinence.
BEHAVIORALControl arm
Routine residential treatment and orientation to continuing care.
Sponsors
US Department of Veterans Affairs
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Participants were recruited from consecutive veterans who successful complete the 28-day SARRTP at the Salem VAMC and the 21-day SARRTP at the Jackson VAMC. Participants who are uninterested in aftercare, who have unstable housing or other factors that made aftercare participation difficult, will be included to maximize the generalizability of our results.
Exclusion criteria
Individuals who did not live within a 60-minute drive, and those who did not have transportation and a work schedule allowing attendance of aftercare were ineligible.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90 | Assessed at 12 months | Participants who were abstinent was assessed via Form-90 Interview (Form 90I) is a structured interview that assesses substance use and related behaviors over the previous 90 days employing a calendar-based follow-back method that provides continuous measures of substance use, and has good reliability. Measures include days abstinent, days using alcohol, days using drugs, total number of standard drinks, and days of self help meeting attendance. Briefer versions were constructed to collect data via telephone in instances when participants did not return for in-person interviews. As a reliability check on participants' self-report, a collateral interview was employed when contacting informants. Participants who denied use on the Form-90, but had a positive substance use screen were considered to be not abstinent for that follow-up point. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Days Until First Use of Alcohol or Drugs | Baseline to 12 months | — |
| Aftercare Attendance | Assessed at 3-, 6-, 9-, and 12-months | Measures of aftercare attendance include: Percentage of participants who attended at least 1 aftercare session; percentage of participants who attended at least 2 aftercare sessions/month for at least 3, 6, 9 and 12 months; and percentage of participants who passed the VAMC's SUD continuity of care performance measure (a benchmark for retention of clients in aftercare for at least two visits each month for 3 months following initial treatment) |
| Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Assessed at 3 and 6 months | Participants who were abstinent was assessed via Form-90 Interview (Form 90I) is a structured interview that assesses substance use and related behaviors over the previous 90 days employing a calendar-based follow-back method that provides continuous measures of substance use, and has good reliability. Measures include days abstinent, days using alcohol, days using drugs, total number of standard drinks, and days of self help meeting attendance. Briefer versions were constructed to collect data via telephone in instances when participants did not return for in-person interviews. As a reliability check on participants' self-report, a collateral interview was employed when contacting informants. Participants who denied use on the Form-90, but had a positive substance use screen were considered to be not abstinent for that follow-up point. |
| Days of Substance Abuse (Across the Prior 90 Days) | Assessed at Baseline, 3-, 6-, and 12-month follow-up | — |
| Rates of Hospitalization (Across the Prior 90 Days) | Assessed at Baseline, 3-, 6-, and 12-months | Number of days hospitalized for any reason per the previous 90 days |
| Self-help Support Group Attendance | Assessed over the past 90 days at 3, 6 and 12 months, and cumulative over 1 year | — |
Countries
United States
Participant flow
Recruitment details
426 Consecutive Graduates Screened for Eligibility, 243 (57%) of those were excluded. \[203 (48%) not within a 60-minute drive of aftercare; 15 (4%) no transportation, or aftercare not available due to work schedule; 24 (6%) did not consent; 1 excluded for unknown reason(s)\]
Participants by arm
| Arm | Count |
|---|---|
| Standard Treatment (STX) Control condition: Routine residential treatment and orientation to continuing care.
An addiction therapist from the participants' treatment program met with each participant for an individual aftercare orientation session during the final 4 days of the initial treatment program and again during the ninth week of aftercare. Individuals were also encouraged to get an AA or NA sponsor during this session. | 91 |
| Contracts, Prompts and Reinforcement (CPR) Contracting, Prompting & Reinforcing Abstinence & Attendance: Contingent reinforcement of abstinence and prompting of AA/NA attendance
CPR participants received the STX aftercare orientation except they were also provided with the contracting intervention during the orientation sessions, as well as the prompting and reinforcement components of the intervention.
* Contracting. Participant's completed a behavioral contract for continuing care participation that took approximately 20 minutes to complete during their final 4 days in initial treatment and after 9 weeks of participation in continuing care.
* Prompting. CPR participants received prompts (mailed appointment cards, telephone reminders) to attend all of their aftercare appointments and AA/NA meetings, and following missed aftercare sessions for 1 year (or until discharged from treatment).
* Reinforcement. CPR participants received social reinforcement (certificates, honor roll) for attending group therapy. | 92 |
| Total | 183 |
Baseline characteristics
| Characteristic | Standard Treatment (STX) | Contracts, Prompts and Reinforcement (CPR) | Total |
|---|---|---|---|
| Age, Continuous | 50.63 years STANDARD_DEVIATION 7.88 | 49.55 years STANDARD_DEVIATION 8.63 | 50.09 years STANDARD_DEVIATION 8.26 |
| Region of Enrollment United States | 91 participants | 92 participants | 183 participants |
| Sex: Female, Male Female | 3 Participants | 5 Participants | 8 Participants |
| Sex: Female, Male Male | 88 Participants | 87 Participants | 175 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 91 | 0 / 92 |
| serious Total, serious adverse events | 0 / 91 | 0 / 92 |
Outcome results
Primary
Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90
Participants who were abstinent was assessed via Form-90 Interview (Form 90I) is a structured interview that assesses substance use and related behaviors over the previous 90 days employing a calendar-based follow-back method that provides continuous measures of substance use, and has good reliability. Measures include days abstinent, days using alcohol, days using drugs, total number of standard drinks, and days of self help meeting attendance. Briefer versions were constructed to collect data via telephone in instances when participants did not return for in-person interviews. As a reliability check on participants' self-report, a collateral interview was employed when contacting informants. Participants who denied use on the Form-90, but had a positive substance use screen were considered to be not abstinent for that follow-up point.
Time frame: Assessed at 12 months
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol and drugs | 40 participants |
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol | 47 participants |
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90 | Abstinence from drugs | 55 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol and drugs | 38 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol | 51 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90 | Abstinence from drugs | 49 participants |
Secondary
Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90
Participants who were abstinent was assessed via Form-90 Interview (Form 90I) is a structured interview that assesses substance use and related behaviors over the previous 90 days employing a calendar-based follow-back method that provides continuous measures of substance use, and has good reliability. Measures include days abstinent, days using alcohol, days using drugs, total number of standard drinks, and days of self help meeting attendance. Briefer versions were constructed to collect data via telephone in instances when participants did not return for in-person interviews. As a reliability check on participants' self-report, a collateral interview was employed when contacting informants. Participants who denied use on the Form-90, but had a positive substance use screen were considered to be not abstinent for that follow-up point.
Time frame: Assessed at 3 and 6 months
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol (3 month) | 65 participants |
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol and drugs (6 months) | 43 participants |
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol (6 month) | 50 participants |
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from drugs (3 month) | 64 participants |
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from drugs (6 month) | 51 participants |
| Standard Treatment (STX) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol and drugs (3 month) | 57 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from drugs (6 month) | 55 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol (3 month) | 69 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol and drugs (6 months) | 43 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from drugs (3 month) | 62 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol (6 month) | 61 participants |
| Contracts, Prompts and Reinforcement (CPR) | Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90 | Abstinence from alcohol and drugs (3 month) | 57 participants |
Secondary
Aftercare Attendance
Measures of aftercare attendance include: Percentage of participants who attended at least 1 aftercare session; percentage of participants who attended at least 2 aftercare sessions/month for at least 3, 6, 9 and 12 months; and percentage of participants who passed the VAMC's SUD continuity of care performance measure (a benchmark for retention of clients in aftercare for at least two visits each month for 3 months following initial treatment)
Time frame: Assessed at 3-, 6-, 9-, and 12-months
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Standard Treatment (STX) | Aftercare Attendance | Attended at least 12 months of treatment | 10 percentage of participants |
| Standard Treatment (STX) | Aftercare Attendance | Attended at least 6 months of treatment | 35 percentage of participants |
| Standard Treatment (STX) | Aftercare Attendance | Attended at least 1 aftercare session | 97 percentage of participants |
| Standard Treatment (STX) | Aftercare Attendance | Passed the SUD continuity of care measure | 58 percentage of participants |
| Standard Treatment (STX) | Aftercare Attendance | Attended at least 3 months of treatment | 64 percentage of participants |
| Standard Treatment (STX) | Aftercare Attendance | Attended at least 9 months of treatment | 22 percentage of participants |
| Contracts, Prompts and Reinforcement (CPR) | Aftercare Attendance | Passed the SUD continuity of care measure | 70 percentage of participants |
| Contracts, Prompts and Reinforcement (CPR) | Aftercare Attendance | Attended at least 9 months of treatment | 35 percentage of participants |
| Contracts, Prompts and Reinforcement (CPR) | Aftercare Attendance | Attended at least 6 months of treatment | 48 percentage of participants |
| Contracts, Prompts and Reinforcement (CPR) | Aftercare Attendance | Attended at least 12 months of treatment | 16 percentage of participants |
| Contracts, Prompts and Reinforcement (CPR) | Aftercare Attendance | Attended at least 3 months of treatment | 76 percentage of participants |
| Contracts, Prompts and Reinforcement (CPR) | Aftercare Attendance | Attended at least 1 aftercare session | 97 percentage of participants |
Secondary
Days of Substance Abuse (Across the Prior 90 Days)
Time frame: Assessed at Baseline, 3-, 6-, and 12-month follow-up
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Standard Treatment (STX) | Days of Substance Abuse (Across the Prior 90 Days) | % of days using alcohol or drugs (Baseline) | 51 percentage of 90 days | Standard Deviation 33 |
| Standard Treatment (STX) | Days of Substance Abuse (Across the Prior 90 Days) | % of days using alcohol or drugs (6 month) | 11 percentage of 90 days | Standard Deviation 23 |
| Standard Treatment (STX) | Days of Substance Abuse (Across the Prior 90 Days) | % of days using alcohol or drugs (3 month) | 6 percentage of 90 days | Standard Deviation 17 |
| Standard Treatment (STX) | Days of Substance Abuse (Across the Prior 90 Days) | % of days using alcohol or drugs (12 month) | 15 percentage of 90 days | Standard Deviation 28 |
| Contracts, Prompts and Reinforcement (CPR) | Days of Substance Abuse (Across the Prior 90 Days) | % of days using alcohol or drugs (3 month) | 7 percentage of 90 days | Standard Deviation 19 |
| Contracts, Prompts and Reinforcement (CPR) | Days of Substance Abuse (Across the Prior 90 Days) | % of days using alcohol or drugs (Baseline) | 58 percentage of 90 days | Standard Deviation 29 |
| Contracts, Prompts and Reinforcement (CPR) | Days of Substance Abuse (Across the Prior 90 Days) | % of days using alcohol or drugs (12 month) | 15 percentage of 90 days | Standard Deviation 31 |
| Contracts, Prompts and Reinforcement (CPR) | Days of Substance Abuse (Across the Prior 90 Days) | % of days using alcohol or drugs (6 month) | 8 percentage of 90 days | Standard Deviation 19 |
Secondary
Days Until First Use of Alcohol or Drugs
Time frame: Baseline to 12 months
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Standard Treatment (STX) | Days Until First Use of Alcohol or Drugs | 200.74 days | Standard Deviation 136.31 |
| Contracts, Prompts and Reinforcement (CPR) | Days Until First Use of Alcohol or Drugs | 202.43 days | Standard Deviation 140.46 |
Secondary
Rates of Hospitalization (Across the Prior 90 Days)
Number of days hospitalized for any reason per the previous 90 days
Time frame: Assessed at Baseline, 3-, 6-, and 12-months
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Standard Treatment (STX) | Rates of Hospitalization (Across the Prior 90 Days) | Days of hospitalization (Baseline) | 9.23 days | Standard Deviation 14.42 |
| Standard Treatment (STX) | Rates of Hospitalization (Across the Prior 90 Days) | Days of hospitalization (3 months) | 1.18 days | Standard Deviation 4.74 |
| Standard Treatment (STX) | Rates of Hospitalization (Across the Prior 90 Days) | Days of hospitalization (6 months) | 2.14 days | Standard Deviation 8.74 |
| Standard Treatment (STX) | Rates of Hospitalization (Across the Prior 90 Days) | Days of hospitalization (12 months) | 1.47 days | Standard Deviation 4.07 |
| Contracts, Prompts and Reinforcement (CPR) | Rates of Hospitalization (Across the Prior 90 Days) | Days of hospitalization (12 months) | 2.08 days | Standard Deviation 11.27 |
| Contracts, Prompts and Reinforcement (CPR) | Rates of Hospitalization (Across the Prior 90 Days) | Days of hospitalization (Baseline) | 6.87 days | Standard Deviation 12.39 |
| Contracts, Prompts and Reinforcement (CPR) | Rates of Hospitalization (Across the Prior 90 Days) | Days of hospitalization (6 months) | 4.23 days | Standard Deviation 14.73 |
| Contracts, Prompts and Reinforcement (CPR) | Rates of Hospitalization (Across the Prior 90 Days) | Days of hospitalization (3 months) | 1.93 days | Standard Deviation 8.21 |
Secondary
Self-help Support Group Attendance
Time frame: Assessed over the past 90 days at 3, 6 and 12 months, and cumulative over 1 year
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Standard Treatment (STX) | Self-help Support Group Attendance | Days of AA or NA attendance (3 months) | 20.18 days | Standard Deviation 21.16 |
| Standard Treatment (STX) | Self-help Support Group Attendance | Days of AA or NA attendance (6 months) | 18.14 days | Standard Deviation 25.9 |
| Standard Treatment (STX) | Self-help Support Group Attendance | Days of AA or NA attendance (12 months) | 12.41 days | Standard Deviation 21.57 |
| Standard Treatment (STX) | Self-help Support Group Attendance | Total Days of AA or NA attendance at 1 year | 45.7 days | Standard Deviation 57.3 |
| Contracts, Prompts and Reinforcement (CPR) | Self-help Support Group Attendance | Total Days of AA or NA attendance at 1 year | 54.6 days | Standard Deviation 58.2 |
| Contracts, Prompts and Reinforcement (CPR) | Self-help Support Group Attendance | Days of AA or NA attendance (3 months) | 23.44 days | Standard Deviation 22.29 |
| Contracts, Prompts and Reinforcement (CPR) | Self-help Support Group Attendance | Days of AA or NA attendance (12 months) | 14.18 days | Standard Deviation 23.21 |
| Contracts, Prompts and Reinforcement (CPR) | Self-help Support Group Attendance | Days of AA or NA attendance (6 months) | 21.99 days | Standard Deviation 26.5 |