James R. McKay1
(1)
Center on the Continuum of Care in the Addictions, University of Pennsylvania, 3440 Market Street, Suite 370, Philadelphia, PA 19104, USA
James R. McKay
Email: mckay_j@mail.trc.upenn.edu
Abstract
Reviews of the continuing care research literature indicate that interventions that feature longer planned durations and active efforts to deliver the treatment components are more likely to show positive effects than other interventions. However, this literature has a number of limitations, including a focus on inpatient samples, treatment completers, and traditional treatment models and interventions. In addition, these studies have not attempted to identify which patients are likely to benefit the most from continuing care. Finally, there have been few tests of interventions that attempt to build strengths and other positive factors consistent with a recovery-oriented approach to continuing care. Recent findings from three addiction disease management research programs that have attempted to address many of these limitations are presented and discussed. In addition, several research-based recommendations for improving continuing care are offered, including reducing patient burden, providing incentives for participation, combining continuing care with other services, actively linking patients to other recovery supports, and making the interventions more recovery-oriented. Finally, the potential problems associated with considering abstinence as a requirement for being “in recovery” while participating in extended continuing care or other disease management interventions are discussed.
Keywords
Addiction recovery managementContinuing care interventionsTreatment systems
Introduction
The goals of this chapter are to review evidence for the effectiveness of continuing care in addictions and to more broadly discuss the role of continuing care in the recovery process. At this point, there is a body of research on continuing care, and the findings from these studies that have been summarized in prior reviews tell a fairly consistent story [1, 2]. At the same time, there have been major changes to the addiction treatment system over the past 20 years that raise questions about how much the findings from many of these studies tell us about the effectiveness of continuing care within contemporary treatment systems or in the systems that are likely to emerge in the coming years.
Prior to 1990, continuing care was fairly simple to define. It was the outpatient phase of treatment that (hopefully) followed the completion of an inpatient or residential treatment experience, and it was consequently often referred to as “aftercare.” The nature of continuing care in those days was also remarkably consistent. It was almost always weekly group counseling with a heavy 12-step focus, typically provided over 3–6 months [1]. Since 1990, the picture has gotten much more complicated. Most patients are now treated entirely in outpatient settings [3], so the distinction between the initial and continuing care phases of treatment is much less clear. Moreover, continuing care may begin at intake rather than discharge from the first treatment phase, may take any number of forms, and may be provided in settings other than a typical addiction treatment program. One might even ask whether “continuing care” will continue to exist as a separate phase of treatment or will instead become a component of disease management-oriented treatment systems.
Therefore, in addition to briefly reviewing the results of continuing care studies, this chapter closely examines the limitations of this literature with regard to determining the effectiveness of continuing care contemporary newer systems of care. Several newer studies that attempt to address the limitations in prior studies are described. The degree to which findings from continuing care studies inform our understanding of recovery is also discussed. In most cases, the endpoints in continuing care studies have been measures of alcohol and drug use, whereas current writings on recovery stress that abstinence is necessary but not sufficient, and that true “recovery” involves improvements in other important areas of functioning [4].
What Contributes to the Chronic Nature of Substance Use Disorders?
Not all individuals with substance use disorders have chronic forms of these disorders. However, at least half of the patients who enter the formal treatment system will have multiple treatment episodes [5]. In our treatment studies at the University of Pennsylvania, we found that, for example, patients have undergone an average of three or four prior treatments [6]. There are a number of biological, psychological, and social factors that appear to contribute to the chronic nature of substance use disorders. Some of these factors are themselves relatively slow to change or even permanent, including genetic vulnerability, neurocognitive deficits, dysfunctional beliefs and expectancies regarding substance use, family and social problems and lack of support for recovery, deficits in life skills, and high-risk environments [7–9]. Because these risk factors persist for long periods, it is no surprise that many individuals with substance use disorders experience multiple relapses over time. In fact, the real surprise is that so many people manage to recover.
What Are the Implications of Having a Chronic Disorder?
Chronic disorders come in different shapes and sizes. With disorders such as hypertension and type I diabetes, patients seldom achieve remission once the disorder has been diagnosed [10]. The severity of the disorder may wax and wane over time – for example, blood pressure will be higher at some points than at others – but patients usually do not achieve “normal” blood pressure or glucose levels unless they stay on their medications. In other words, these disorders are chronic and relatively constant. With substance use disorders, on the other hand, many individuals achieve complete remission following a treatment episode and may maintain that status for several months or years while not in treatment, only to eventually relapse to heavy levels of use [11]. Substance use disorders can therefore be chronic but intermittent, at least for some individuals.
Therefore, continuing care for substance use disorders must be flexible if it is to be efficacious and cost-effective. Some patients will need long-term, more highly structured continuing care, whereas others will need very little. Still others, perhaps the majority of patients who end up in the formal treatment system, will need continuing care that can be adjusted up or down in intensity and frequency over time as they go through alternating periods of abstinence and use [1, 2]. During periods of abstinence, low level monitoring may be optimal as it places minimal burden on the patient and reduces costs [12]. However, when risk levels rise or episodes of actual substance use begin, monitoring needs to be able to be ratcheted up to the level of treatment to interrupt and address whatever processes are leading to further deterioration [5].
Effective management of chronic disorders also requires that patients are able to make good use of nontreatment supports – both within themselves and in the community. The ability to learn and to practice good “self-care” is seen as a very important part of the management of chronic disorders of all types [13]. One of the key goals of treatment – particularly continuing care – is to equip patients to engage in the basic tasks of good self-care. Although these tasks vary from disorder to disorder, they generally include self-monitoring of status and symptoms, coping with stressors, and interacting effectively with service providers and other sources of support. Continuing care can also help promote strong recoveries by linking patients to sources of support in the community [14]. These might include employment and educational opportunities, parenting and childcare services, medical or psychiatric care, housing, and recovery centers.
Finally, early onset addiction can severely disrupt the development of effective life skills in many areas of functioning. Therefore, significant numbers of patients who achieve abstinence will nonetheless still face formidable challenges in their attempts to develop the kinds of meaningful and satisfying lives that can provide a buffer against relapse. This is why recovery has to be more than the achievement of abstinence.
In summary, continuing care for individuals with chronic forms of substance use disorders needs to be flexible with regard to frequency, intensity, and focus; able to provide successful linkage to other sources of professional and paraprofessional support in the community; and able to promote self-care and the development of life skills.
Research Findings on the Effectiveness of Continuing Care
Although the number of published studies of continuing care for substance use disorders is small relative to the number of published studies of initial or primary treatment, the number of such studies is steadily increasing. In fact, there are now more than 20 published controlled studies that compare various approaches to continuing care for patients who have completed some form of primary treatment. Most of these studies have been reviewed in detail elsewhere [1, 2], with the following conclusions offered:
· Half of the studies find evidence for the effectiveness of a particular continuing care intervention.
· Studies that compare an active continuing care intervention against a minimal or no continuing care condition are more likely to yield positive findings than studies that compare two or more active continuing care conditions.
· Continuing care interventions that feature longer planned durations of care and/or active efforts to deliver the treatment to the patient are more likely to yield positive findings than interventions that do not have these features.
· More recent studies are more likely to find significant treatment effects than studies published prior to the late 1990s.
Examples of continuing care interventions that yielded significant treatment effects include home visits by psychiatric nurses [15], behavioral couples therapy [16], structured coping skills-based treatments [17, 18], telephone counseling [6, 19, 20], and comprehensive interventions that involved active linkage to community resources [21, 22].
Limitations of Published Research on Continuing Care
Unfortunately, the treatment studies that were included in these reviews have a number of limitations, which potentially reduce the amount of useful information that can be gleaned from the results and used to improve continuing care. The majority of studies were done with treatment completers drawn from inpatient samples who were participating in what could be called a traditional model of care and receiving fairly conventional treatment approaches. These studies also fail to differentiate patients who are most likely to benefit from continuing care.
Focus on Inpatient Samples
The majority of the continuing care studies included in the McKay [1, 2] reviews made use of patients who had completed inpatient or residential treatment – 75% of the studies, in fact. Although continuing care is highly recommended for such patients, they currently make up only a small percentage of people in addiction treatment. The vast majority of patients in specialty care for substance use disorders receive outpatient treatment. It is therefore important to consider whether patients completing residential or inpatient care face the same issues as those in outpatient treatment.
In most cases, patients now only end up in residential or inpatient care if they have some combination of severe addiction, co-occurring disorders, poor motivation, unsuccessful outpatient treatment experiences, or living situations that will not be supportive of abstinence [23]. While in treatment, these individuals generally do not have access to alcohol or drugs, and they do not have to confront risky situations. This combination of multiple risk factors for relapse coupled with no opportunities to practice in vivo coping behaviors makes a powerful case for continuing care upon discharge.
Patients in outpatient treatment, on the other hand, may have fewer risk factors for relapse than those who are admitted to inpatient settings, although it is not uncommon to see outpatients with some risk factors. Perhaps more important, individuals who are able to remain engaged in outpatient care long enough to complete the initial phase of care and become eligible for continuing care have already demonstrated some ability to cope successfully with ready access to alcohol and drugs as well as other risky situations that can easily lead to relapse. Therefore, these patients may not need as much continuing care to achieve good longer-term outcomes. If that were the case, studies that focus on inpatient and residential samples may overstate the effect of continuing care within an outpatient service delivery system.
Focus on Treatment Completers
Continuing care has generally been thought of as a phase of treatment that is delivered only to those patients who complete an initial phase of care. Therefore, only more successful patients have been included in studies of continuing care. This bias is likely less severe in studies of patients recruited from residential or inpatient treatment, as the majority of patients in these settings complete treatment, due to the fact that these interventions are relatively short and provided in controlled environments. However, dropout rates are much higher in outpatient treatment [24], which means that patients who receive continuing care in traditional service delivery models are clearly not representative of patients who begin treatment.
These potential biases could work in two directions. In outpatient populations, the bias toward more successful patients might result in an underestimation of the benefits of continuing care because of ceiling effects. Most of these patients will do relatively well, so there may be less room for continuing care to show an effect. On the other hand, if patients who drop out early do not benefit from efforts to engage them in continuing care, the inclusion of these patients in studies could diminish or wash out the impact of continuing care on more successful patients.
Focus on Traditional Treatment Models
Most of the controlled trials of continuing care have been done within the context of traditional treatment models, in which patients step down through discrete levels of care. Examples of these models include 4 weeks of inpatient or intensive outpatient treatment followed by weekly outpatient care. In these models, the difference between initial treatment and continuing care is very clear, and it often involved changes in treatment setting or facility as well as in frequency and intensity. In many settings, however, the distinction between these two phases of care is now much less distinct, particularly in systems that rely primarily on outpatient treatment [1]. It is not clear to what extent findings regarding the effectiveness of continuing care generated in these more traditional treatment models generalize to more contemporary models of care. This issue is of course related to the first two issues raised above.
Failure to Consider Which Patients Most Need Continuing Care
The inclusion/exclusion criteria for studies of continuing care have typically been similar to criteria used in studies of initial or primary treatment. Participants must have a substance use disorder and someone who can serve as a locator to facilitate follow-up, and they must not be too impaired with a major psychiatric disorder or cognitive deficit. In addition, as discussed earlier, they must also have completed some minimum amount of an initial treatment. Interestingly, studies almost never specify that participants must show evidence that they have a chronic form of a substance use disorder, such as some number of prior treatment experiences followed by relapse or a history of failure to complete treatment episodes.
One might argue that anyone who enters the formal addiction specialty care treatment system in fact has a chronic substance use disorder, and therefore all patients are likely to benefit from effective continuing care [10]. However, most disease management programs for other disorders focus efforts on patients who have utilized a considerable amount of treatment services over the prior year or two, which is taken as an indication that their disorders are not well managed with conventional treatment [25]. It is conceivable that results of published continuing care studies might have been different if only patients with, say, four or more prior detoxification or treatment episodes over the past 2 years were included in the study sample.
Focus on Conventional Approaches to Continuing Care
In addition to the concerns noted above with regard to which patients have been included in continuing care studies and the types of treatment systems that have been studied, several characteristics of the interventions themselves raise questions about how relevant the research findings are to recovery-oriented systems of care. Specifically, most treatments studied have (1) focused primarily on reducing deficits rather than building strengths, (2) been fixed rather than flexible, and (3) not considered patient preference to any degree.
Deficits vs. Strengths
The majority of continuing care studies included in the reviews of that literature have tested interventions designed to reduce deficits in coping skills and biases in cognitions and beliefs (CBT-type interventions) or to sustain endorsement and participation in 12-step models [2, 26]. Both kinds of interventions have elements that attempt to reduce deficits and those that try to increase strengths. In the case of 12-step interventions, for example, the treatment aims to reduce problematic behavior (e.g., self-centeredness, refusal to give up control, other character defects, and the mistaken belief that one will be able to drink normally again) and to develop strengths and prorecovery behaviors (e.g., helping others, offering amends for past transgressions, engaging in social interactions and relationships that do not involve substance use). Coping skills treatments such as CBT do attempt to reinforce strengths to some degree, but the emphasis in most components of the intervention and in most sessions is really on fixing problems and deficits in behaviors and cognitions [27]. The assumption is that more rewarding activities in recovery will be possible if the problems and deficits that sustain continued substance use are ameliorated through the identification and rehearsal of better coping behaviors and the correction of problematic or biased cognitions.
This emphasis in most continuing care treatments on addressing deficits is at odds to some degree with a more recovery-oriented approach, which focuses to a greater extent on identifying, nurturing, and further developing an individual’s skills, talents, and interests [14, 28]. During a continuing care treatment session, the difference between these two orientations could be profound. For example, in a typical coping skills intervention, most sessions start with a review of any episodes of use, followed by a functional analysis to better understand what went wrong if a slip or relapse occurred. Next, upcoming high-risk episodes are reviewed, and potential coping responses are identified and rehearsed [29].
In a more recovery-oriented approach to continuing care, there is greater emphasis on the identification, monitoring, and supporting of life goals that are selected by the patient. These goals are usually framed in a positive direction – “I want to spend more time being physically active outside” – and the underlying motive for the goal is also positive – “because it is enjoyable for me.” Contrast this with a typical goal in a social skills treatment – “I want to get better at refusing drinks when they are offered to me” – which follows from a deficit-based motive or explanation – “because I am impulsive and don’t think through things.” Writing on how best to maintain behavior change over time, Rothman [30] observed that fear of negative consequences may help someone stop smoking or using alcohol and drugs, but enjoyment of the benefits that these behavior changes might bring is probably necessary to sustain changes in these behaviors.
Little Consideration of Patients’ Preference
Recovery-oriented treatment places a great deal of emphasis on the importance of patients’ choice with regard to treatment goals and methods to achieve those goals [14, 28]. The importance of patients’ choice has also been stressed in other areas of medicine, especially with regard to the management of chronic diseases [13, 31]. Conversely, most continuing care interventions that have been studied in controlled trials come with a set of goals and methods that patients are expected to endorse and follow through on. This is particularly true of 12-step-oriented interventions, where there is very little room for patients’ choice. In fact, patients are urged to “get out of the driver’s seat,” surrender their will to a higher power, and follow the directives of the program to attend meetings and work the 12 steps. The point here is not that this approach does not work – there is plenty of evidence that 12-step programs can provide highly effective continuing care – but that there is little room for patient choice or preference.
Fixed vs. Flexible
Most of the continuing care interventions that have been included in reviews could be said to be relatively rigid or fixed. That is, the interventions were delivered in a standardized fashion according to guidelines provided in manuals and were not modified or adjusted to a significant degree on the basis of changes in patients’ response over time.
Problems Further Upstream
We have seen that the literature on continuing care is limited in a number of significant ways, which raises questions about the true effectiveness of these interventions. An even larger problem concerns how few people receive any continuing care at all, due to problems with engagement, retention, and transition to continuing care.
The Engagement Problem
Epidemiological studies have shown that overwhelming majority of individuals with substance use disorders never enter formal treatment or self-help organizations [32]. Of these people, many recover and do not experience another episode of dependence or abuse. However, this still leaves a very sizeable number of people who do not achieve stable remission, instead either continuing to use consistently or going through repeated periods of heavy use separated by some reductions in use or abstinence. People in this group might well benefit from treatment that includes some sort of extended care phase, but something about treatment is sufficiently unappealing that they never engage in it. With regard to continuing care, the elephant in the room that no one wants to talk about has been that most people with substance use disorders do not want standard treatment, much less extended versions of it.
The Retention Problem
In order for individuals with substance use disorders to receive continuing care of any sort, they have to participate in treatment for more than a few weeks. This is particularly important in a recovery-oriented model of care, in which the goal of treatment is more than simply the initiation of abstinence. Recovery requires sustained behavior change, including longer abstinence or sharply decreased use, connection to and engagement with community supports, and progress toward meaningful social and employment goals. According to recent statistics, however, average stays in IOP and OP are 46 and 76 days, respectively [24]. This is clearly not enough time for most patients to make significant progress toward a real recovery.
The Transition Problem
Significant numbers of patients who complete a first phase of treatment fail to make the transition to step down care [33, 34]. This appears to be due to a number of reasons, including the lack of availability of continuing care at the facility, a desire on the part of the patient to be “done” with treatment, and other barriers such as distance from the facility and competing work and family responsibilities. At the very least, the shift from one phase of care to the next is a natural point for patients to reexamine whether they want to continue, and in many cases the answer appears to be “no.”
What We Really Know About Continuing Care and Recovery
Limitations in the body of research on the effectiveness of continuing care likely mean that we know less than we think about how well these interventions actually work. We know that most people with alcohol or drug use disorders do not want standard substance abuse treatment, and therefore either fail to enter treatment or drop out early, long before they receive any continuing care. Of the relatively small percentage of the patients who stay in treatment long enough to be eligible for continuing care, most receive very little if any continuing care. Within this group, it does appear that continuing care treatments that have a longer planned duration of care and involve more active efforts to deliver the intervention are more likely to be effective [1, 2]. However, the evidence here is indirect – few studies have compared long vs. short forms of the same continuing care intervention – and it comes from carefully conducted research studies where investigators go to great lengths to retain participants in both the clinical interventions and the research follow-ups. Retention rates in continuing care in more typical treatment programs are likely to be lower [34].
A New Generation of Continuing Care Studies
Several relatively recent studies have examined the effectiveness of continuing care models that seek to support all patients in addiction treatment, not just those who have completed an initial phase of care. These interventions all feature active outreach efforts designed to maintain contact with patients over long periods of time so that continuing care can be delivered, even when patients have relapsed or lost motivation for recovery.
The work of Dennis, Scott, and colleagues [35, 36] addresses some of the limitations noted here in the continuing care literature. These investigators have developed and evaluated a true continuing care model, referred to as “Recovery Management Checkups,” or RMC, in which all patients who enter treatment become eligible for an extended monitoring program that strives to reengage them if they relapse over the next 2–3 years. In this protocol, substance abusers who have entered treatment are followed and interviewed every 3 months. For those not currently in treatment or in a controlled environment such as jail, the need for further treatment is determined through a relatively brief assessment with very specific criteria regarding out-of-control use. Individuals who meet the criteria for need for treatment are immediately transferred to a linkage manager, who uses motivational interviewing techniques to help the participant recognize and acknowledge the problem and need for treatment, addresses any existing barriers to reentering treatment, and arranges scheduling and transportation to treatment.
The RMC protocol was first evaluated in 448 adults who were randomized to RMC or quarterly research follow-ups and followed for 24 months [35]. The results of the study indicated that the RMC intervention led to better management of the patients over time. First, patients in RMC were more likely to be readmitted to treatment (60% vs. 51%), were readmitted sooner (mean of 376 vs. 600 days), and received more treatment during the 2-year follow-up (mean of 62 vs. 40 days) than those in the control condition. Second, patients in RMC had better substance use outcomes than those in the control condition. Specifically, RMC patients were less likely to meet criteria for needing treatment in five or more quarters than patients in the control condition (23% vs. 32%) and were less likely to be in need of treatment in the final quarter of the follow-up (43% vs. 56%). These effects were generally small, but consistently favored RMC over the comparison condition.
The Chestnut Health group has conducted a second study with a new version of RMC that was modified to address the limitations observed in the first study [36]. The self-report assessment to determine need for treatment was augmented with urine testing, which increased the percentage of participants who were found to need treatment at each assessment point over the rates observed in the first study (44% vs. 30% of those interviewed). Transportation assistance was provided to increase the percentage of participants found to be in need of treatment who actually completed an intake assessment. Finally, several practices were put in place to increase retention in those participants who did complete an intake appointment at a treatment program. These practices involved closer collaboration between the research team and the treatment programs to reengage participants in treatment who drop out after intake and to prevent hasty administrative discharges.
These modifications increased the effectiveness of the intervention to a considerable degree over what was achieved in the first study [36]. A higher percentage of participants deemed in need of treatment attended the linkage meeting (99% vs. 75%), completed the assessment (42% vs. 30%), and remained in treatment for a minimum of 14 days (58% vs. 39%). Moreover, the improved RMC intervention produced significantly more days of abstinence during the 2-year follow-up (mean of 480 vs. 430, p < 0.05, d = 0.29) than the comparison condition. However, this effect, which translates into about 2 extra days of abstinence per month, was relatively small in magnitude.
Morgenstern and colleagues studied the effectiveness of an extended, intensive case management intervention in substance-dependent women receiving Temporary Assistance for Needy Families (i.e., TANF) [37]. As with the RMC intervention, participants were enrolled at the start of treatment, not after completing an initial phase of care. In this intervention, case management services were provided for 15 months. Prior to treatment entry, the case managers met with women at the local welfare office to identify barriers to treatment entry and address resistance to treatment. Plans were developed and implemented to solve childcare, transportation, and housing problems, and motivational counseling was provided as needed. Home visits and other outreach activities were also used for women who were having trouble in achieving engagement. Once the participant entered treatment, the case manager met with her weekly and continued to provide help with coordinating services. Frequency of contact was slowly titrated to twice monthly, but it could be increased up to daily during crisis periods. Small value incentives were also provided for attending treatment sessions.
The effectiveness of this intervention was compared to usual outpatient care in a sample of 302 women. Results indicated that the intensive case management intervention produced higher levels of treatment initiation, engagement, and retention, compared to usual care. Furthermore, women who received the intensive case management intervention had higher rates of abstinence throughout the follow-up, with the greatest difference obtained at 15 months (43% vs. 26% abstinent). Across the 15 month follow-up, the prevalence of abstinence within each 1 month segment was 75% higher in women who received the case management intervention (odds ratio = 1.75, p = 0.025). In a second study of case management, Morgenstern and colleagues have again found that participants who are provided with case management in addition to treatment as usual have better substance use outcomes than those who receive treatment as usual only [38].
Our group at Penn has also moved toward providing extended monitoring and counseling to patients who begin the protocol shortly after they enter an intensive outpatient program (IOP), rather than at graduation from IOP. The 18-month-long adaptive protocol is built around 20-min telephone contacts that consist of a brief structured assessment of risk for relapse and problem-focused counseling. The intervention includes CBT techniques such as monitoring of progress, identification of high-risk situations, and rehearsal of improved coping behaviors. The calls are scheduled at 1-week intervals early in the protocol, with the frequency decreasing over time to one call per month. When risk levels increase, participants receive stepped-up care that can include more frequent telephone sessions, several sessions of motivational interviewing [39], a course of relapse prevention, or linkage back to the IOP.
This intervention addresses most of the primary goals of the “Chronic Care Model,” as described by Wagner et al. [13]. This disease management model specifies regular, extended contact between patients and service providers; interventions to increase patient confidence and skills to manage chronic conditions (e.g., goal setting, identification of barriers to reaching goals, development of plans to overcome barriers); links to patient-oriented community resources; the use of accurate and timely patient data to monitor progress and guide interventions; and provision of support to facilitate improved self-management.
The intervention was compared to two comparison conditions in a recent study. Patients who had completed 3 weeks of a 3-month long IOP were randomly assigned to continue with treatment as usual (TAU), to continue with TAU plus get the telephone monitoring and counseling condition described above (TMC), or to continue with TAU and receive brief monitoring telephone calls on the same schedule as that in the TMC intervention (TM). The calls in TM consisted of the same progress assessment used in TMC and provided very brief feedback on the results of the assessment. No counseling was provided in this condition.
The first report from this study focused on alcohol use outcomes during the 18-month period in which TMC and TM were provided [40]. With percent days alcohol use, there was a significant treatment condition × time interaction (p = 0.03). Planned contrast analyses indicated that TMC produced less frequent drinking than TAU at 12 months (p < 0.02), 15 months (p = 0.0002), and 18 months (p = 0.006), and less frequent drinking than TM at 6 months (p = 0.2). TM produced less frequent drinking than TAU at 12 and 15 months (p = 0.03). With a dichotomous outcome measure of any drinking within each 3-month segment of the follow-up, there was a significant main effect for treatment condition (p < 0.05). Planned contrast analyses indicated that rates of any alcohol use within each period were lower in TMC than in TAU across the follow-up (p =. 02). TM and TAU did not differ (p = 0.42).
Analyses were also done to determine whether any factors moderated the main effect results in this trial. The positive effects of extended continuing care were hypothesized to be greater for patients with more severe histories of substance use problems, those with a relatively poor initial response to IOP, and those with other established risk factors for relapse as identified in the research literature (i.e., craving, low self-efficacy, low readiness for change, lack of commitment to abstinence, and negative expectancies). With TMC, the hypotheses were not confirmed. None of the 11 variables examined was a significant moderator of main effects favoring TMC over TAU, indicating that this intervention is effective for a wide range of patients. Conversely, gender and readiness to change moderated the TM effect; TM was more effective than TAU for women and for those with lower readiness to change, but not for men or for individuals higher in readiness [41].
The strong performance of TMC in this study is somewhat surprising, because about 25% of the patients who were randomized to the intervention never began it. Moreover, the patients who did begin the intervention averaged only about 10 of 36 possible continuing care contacts over the 18 months. It is possible that the intervention would produce even stronger effects if rates of participation could be raised. With that goal in mind, we are conducting another telephone continuing care study that tests the impact of low-level incentives on participation in extended telephone continuing care and outcomes. In this study, patients are randomized to receive TAU, TMC, or TMC plus incentives ($10 gift coupon for every continuing care contact completed). Initial results from this study indicate that providing these incentives increases the percentage of patients who begin the TMC protocol (82% vs. 73%) and dramatically increases the percentage of possible continuing care contacts completed (67% vs. 39%) [42].
Possible Solutions to Problems of Engagement and Retention
Reduce Patient Burden in Continuing Care Whenever Possible
Patients may be more willing to initiate and sustain participation in continuing care when the intervention is more convenient and less burdensome than standard, clinic-based group counseling. Such an approach does not need to compromise overall effectiveness. In one of our studies, for example, patients who made reasonable progress toward the goals of IOP actually had better outcomes in a low-burden, telephone-based continuing care intervention, compared to standard group counseling [20]. However, a minority of patients who did not make much progress in IOP did better if continued in regular group counseling at the clinic.
Even brief telephone monitoring and counseling continuing care sessions may be too much for some patients. However, some of these individuals may be willing to come back to the clinic occasionally for brief recovery management “checkups,” which can be used to link the patient back into treatment if necessary. The work of Dennis, Scott, and colleagues, reviewed here, has demonstrated that such an intervention, delivered every 3 months for 2 years or more, results in higher rates of treatment readmission and better substance use outcomes than standard care. Although this approach may not be as effective in preventing relapses as more frequent monitoring, it clearly can interrupt relapses before the consequences become more severe. This approach is also less burdensome for patients and may be less costly to the treatment system.
When a lower intensity continuing care intervention such as telephone monitoring and counseling or recovery management checkups is provided, it is crucial that there be some provision to step up level of care when the patient’s symptoms worsen or status deteriorates [1]. To facilitate this, patients should be monitored as part of these interventions, in a systematic and standardized fashion, using validated assessment tools. Algorithms should be used which specify the scores on these measures that indicate when it is time to change treatment and ideally provide guidance on which interventions to consider adding or switching too. This approach has been referred to as “adaptive treatment,” or “stepped care,” and it holds considerable promise as a strategy for reducing patient burden, reducing costs to the system, and improving outcomes [43]. However, in our experience, patients often are resistant to more intensive interventions when they are not doing well. Therefore, catching deterioration before it has become too severe can be very important.
Provide Incentives for Participation
There is now overwhelming evidence that providing incentives to patients leads to better attendance and higher rates of abstinence [44, 45]. These effects have been found with a wide range of patients and types of reinforcers, including low-cost gifts (canteen vouchers), chances to win prizes in drawings, cash, and gift certificates that over the course of a study can be worth up to $2,000 or more [46]. There was initially considerable resistance on the part of treatment providers to incentive-based interventions, but the results of research studies have been persuasive. The fact that incentives almost always dramatically increase treatment participation has also become seen by providers as a plus. At this point, the main barrier to wider use of incentives appears to be the cost of the incentives themselves, rather than philosophical opposition to the idea.
Rates of continuing care participation can also be increased by incentivizing the treatment providers. Shepard et al. [47] were able to increase the percentage of patients who completed at least five continuing care sessions from 33 to 59% by paying counselors a $100 bonus for each patient who reached that goal. Although five sessions may seem like a very low bar, the participants in this study were opiate-dependent patients who had been detoxified and treated in a drug-free program (i.e., no methadone). Rates of attendance in continuing care in this group have been extremely low.
Given the financial constraints virtually all addiction treatment programs operate under these days, the provision of incentives to patients in continuing care – or to the clinicians treating them – may seem impossible. However, in some studies the investigators have found creative ways to support incentives, including through the donations of goods from area business owners who see the value in reducing substance use in the community [46].
Use Leverage When Available
Positive incentives such as gift certificates and prizes are popular with patients, but they are not the only form of leverage available. In the criminal justice system, for example, patients sentenced to drug courts and other forms of mandated treatment are more likely to attend continuing care if failure to attend leads to unwanted consequences such as return to prison [48]. Patients in methadone have also been responsive to contingencies regarding ease of access to methadone that are built around attendance at counseling sessions and urine drug test results [49].
Leverage can also be provided by contracts and social reinforcement. Lash and colleagues have developed an effective intervention to increase attendance in continuing care, which includes contracts, prompts, and low-cost social reinforcements [50]. In the contracting procedures, patients are provided with information on the success rates of patients who do and do not attend continuing care, and they are asked to commit to participate in a specified amount of continuing care and other supports (e.g., AA, individual therapy). Prompts consist of letters from therapists, appointment cards, automated telephone reminders for continuing care appointments, and letters and personal telephone calls following any missed continuing care sessions. The social reinforcement consists of personal letters from counselors with congratulations for attending sessions, certificates for completion of treatment milestones (e.g., 90 days of treatment), and medallions for attending specified numbers of continuing care sessions. The certificates and medallions are typically presented in front of other patients in the therapy groups.
Combine Continuing Care with Other Services
One way to increase sustained participation in continuing care is by linking these interventions in some way to other services that patients are likely to access over time [51]. For example, continuing care can be colocated with or even provided in medical primary care practices or in community mental health centers. The effectiveness of integrated care for medical and substance use disorder problems has been demonstrated in several studies [52, 53]. There is also evidence that linking continuing care with access to housing and employment can be effective with high problem severity populations [54, 55].
Actively Link Patients to Other Recovery Supports
It may be possible to increase rates of recovery by using treatment as an opportunity to aggressively link patients to other sources of support. The most prevalent form of such support is self-help programs. However, only a minority of patients achieve sustained engagement in these programs. Timko and colleagues recently conducted a study to determine whether more intensive referral to self-help groups during outpatient treatment would promote higher and more sustained rates of participation and better outcomes than standard clinic practices [56].
The intensive referral intervention is delivered over the first three treatment sessions of outpatient addiction treatment. The content of the sessions consists of detailed lists of local self-help meetings that had been preferred by other patients, directions to the meetings, and material that describe 3 self-help meetings and addresses common questions and typical concerns about the program. The counselor also arranges a meeting between the patient and a participating member of a self-help group and provides the patient with a journal to record attendance at and reactions to the meetings. Attendance at self-help meetings is monitored over the following two outpatient sessions. For patients who had attended a self-help meeting, attempts are made to link the patient with a sponsor. For those who had not attended a meeting, the process of linking the patients with a self-help volunteer is repeated.
Results from a randomized study indicated that patients in the intensive referral condition had higher rates of overall involvement in self-help programs at 6 months than those in the standard referral condition. Interestingly, the intervention was more effective with patients who were not heavily involved with self-help in the 6 months prior to treatment. Specifically, in patients who were below the 75 percentile on prior 12-step attendance, the intensive referral intervention produced higher rates of attendance at self-help meetings than the standard referral condition (62.3 vs. 40.4 meetings during the 6-month follow-up; p < 0.01). With regard to substance use outcomes, the intensive referral condition produced better alcohol and drug use outcomes at 6 months, as assessed by ASI composite scores, and higher rates of total abstinence from drugs than the standard referral condition [56].
Even with a more effective intervention, there are still patients who will not attend self-help. Therefore, Litt and colleagues developed a treatment intervention designed to help patients change their larger social networks to become more supportive of abstinence [57]. Because 12-step-based self-help was the most readily available potential source of support for abstinence, the intervention still focused on participation in these programs, although making new acquaintances and engaging in enjoyable social activities at AA or other social networks were stressed, rather than other AA components like the higher power and powerlessness. For those participants who were not interested in AA, the intervention focused on increasing other forms of social support for abstinence.
This intervention, referred to as “network support,” was then evaluated in a research study. Participants were randomized to a case management comparison condition (CM), network support (NS), or network support plus incentives for abstinence (NS + ContM). Data from the 1-year follow-up indicated that both network support conditions produced better alcohol use outcomes than case management, as indicated by higher percent days abstinent (about 75% vs. 63%) and higher rates of continuous abstinence in each 3-month period (as high as 40% in NS vs. 20% in CM). Moreover, NS led to greater increases in AA attendance and behavioral and attitudinal support for abstinence. The incentives did not improve outcome over network support alone [57].
Making Continuing Care More Recovery-Oriented
As was noted earlier, the Betty Ford Institute Consensus Panel [4] recently proposed that in order to be “in recovery,” an individual needs to be abstinent from alcohol and drugs and also a functioning member of society. However, much of the continuing care treatment that is currently provided is focused on reducing or eliminating alcohol and drug use, not on improving functioning in other important areas such as work, parenting, and being an active and productive member of one’s community. Part of the problem is that improving functioning has been seen as the purview of social workers and other professions and agencies that are outside the addiction treatment system. However, one of the best hedges against relapse is a life filled with meaningful and enjoyable activities and social connections [58, 59], and many with substance use disorders need considerable help over an extended period to achieve that kind of life. Therefore, greater focus on these goals in the continuing care phase of addiction treatment is certainly warranted, as are more active efforts to link patients to service providers and agencies where such support is available.
It is also worth considering whether the requirement for “abstinence” inhibits rather than facilitates a more recovery-oriented approach to continuing care and long-term disease management in the addictions. With other major psychiatric disorders, the concept of “recovery” is focused on the afflicted individual becoming a fully functioning member of society, despite the fact that symptoms of the disorder are expected to wax and wane over time [28]. No one expects a person with a psychotic or bipolar disorder to achieve the equivalent of “abstinence” from serious and significant symptoms of the disorder. Granted, for many people with serious substance use disorders, long-term abstinence is certainly the preferred outcome. However, a greater emphasis during continuing care on improving personal and social functioning, and less concern about whether the individual has remained totally abstinent, would be more consistent with a recovery focus.
Summary
· In controlled studies with treatment completers, continuing care appears to be effective, particularly if the treatment is extended and features active efforts to deliver the intervention to patients.
· However, most of these studies were done with graduates of inpatient or residential programs, which raises questions about the degree to which these findings generalize to patients in our now largely outpatient service delivery system.
· Many patients who might possibly benefit from continuing care have not been included in these studies, because they never entered treatment, dropped out of the initial phase of care too early to become eligible for continuing care, or did not successfully transition from the initial phase to the continuing care phase.
· More studies are needed that enroll patients closer to the start of treatment, rather than when they complete the initial phase of care, to test whether this approach to disease management produces stronger effects.
· Several recent studies have followed this design and have yielded positive results.
· More work is also needed to develop continuing care interventions that reduce patients’ burden and increase patients’ choice, include incentives for participation, make use of existing leverage when available, integrate with care for other disorders and issues, and provide more active linkage to other recovery supports in the community.
· Finally, a greater focus on nurturing strengths, skills, talents, and interests, rather than the achievement of sustained abstinence, may make continuing care both more appealing and effective and also promote stronger and more stable recoveries.
Acknowledgments
This research was supported by grant P01AA016821 from the National Institute on Alcohol Abuse and Alcoholism and grant K02 DA000361 from the National Institute on Drug Abuse. Additional support was provided by the Medical Research Service of the Department of Veterans Affairs.
References
1.
McKay JR. Treating substance use disorders with adaptive continuing care. Washington, DC: American Psychological Association Press; 2009.CrossRef
2.
McKay JR. Continuing care research: what we’ve learned and where we’re going. J Subst Abuse Treat. 2009;36:131–45.PubMedCrossRef
3.
McLellan AT, Meyers K. Contemporary addiction treatment: a review of systems problems for adults and adolescents. Biol Psychiatry. 2004;56:764–70.PubMedCrossRef
4.
Betty Ford Institute Consensus Panel. What is recovery? A working definition from the Betty Ford Institute. J Subst Abuse Treat. 2007;33:221–8.CrossRef
5.
Dennis ML, Scott CK. Managing addiction as a chronic condition. Addict Sci Clin Pract. 2007;4(1):45–55.PubMedCrossRef
6.
McKay JR, Lynch KG, Shepard DS, Ratichek S, Morrison R, Koppenhaver J, et al. The effectiveness of telephone-based continuing care in the clinical management of alcohol and cocaine use disorders: 12 month outcomes. J Consult Clin Psychol. 2004;72:967–79.PubMedCrossRef
7.
Kalivas PW. Neurobiology of cocaine addiction: implications for new pharmacotherapy. Am J Addict. 2007;16:71–8.PubMedCrossRef
8.
Koob GF. The neurobiology of addiction: a neuroadaptational view relevant for diagnosis. Addiction. 2006;101 Suppl 1:23–30.PubMedCrossRef
9.
Moos RH, Finney JW, Cronkite RC. Alcoholism treatment: context, process, and outcome. New York, NY: Oxford University Press; 1990.
10.
McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. J Am Med Assoc. 2000;284:1689–95.CrossRef
11.
Hser YI, Longshore D, Anglin MD. The life course perspective on drug use: a conceptual framework for understanding drug use trajectories. Eval Rev. 2007;31:515–47.PubMedCrossRef
12.
Humphreys K, Tucker JA. Toward more responsive and effective intervention systems for alcohol-related problems. Addiction. 2002;97:126–32.PubMedCrossRef
13.
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff. 2001;20:64–78.CrossRef
14.
White WL. Recovery management and recovery-oriented systems of care: scientific rationale and promising practices. Pittsburgh, PA: Northeast Addiction Technology Center; 2008.
15.
Patterson DG, MacPherson J, Brady NM. Community psychiatric nurse aftercare for alcoholics: a five-year follow-up study. Addiction. 1997;92:459–68.PubMedCrossRef
16.
O’Farrell TJ, Choquette KA, Cutter HSG. Couples relapse prevention sessions after behavioral marital therapy for male alcoholics: outcomes during the three years after starting treatment. J Stud Alcohol. 1998;59:357–70.PubMed
17.
Bennett GA, Withers J, Thomas PW, Higgins DS, Bailey J, Parry L, et al. A randomized trial of early warning signs relapse prevention training in the treatment of alcohol dependence. Addict Behav. 2005;30:1111–24.PubMedCrossRef
18.
Sannibale C, Hurkett P, Van Den Bossche E, O’Connor D, Zador D, Capus C, et al. Aftercare attendance and post-treatment functioning of severely substance dependent residential treatment clients. Drug Alcohol Rev. 2003;22:181–90.PubMedCrossRef
19.
Horng F, Chueh K. Effectiveness of telephone follow-up and counseling in aftercare for alcoholism. J Nurs Res. 2004;12:11–9.PubMedCrossRef
20.
McKay JR, Lynch KG, Shepard DS, Pettinati HM. The effectiveness of telephone based continuing care for alcohol and cocaine dependence: 24 month outcomes. Arch Gen Psychiatry. 2005;62:199–207.PubMedCrossRef
21.
Brown BS, O’Grady K, Battjes RJ, Farrell EV. Factors associated with treatment outcomes in an aftercare population. Am J Addict. 2004;13:447–60.PubMedCrossRef
22.
Godley MD, Godley SH, Dennis ML, Funk RR, Passetti LL. The effect of assertive continuing care on continuing care linkage, adherence, and abstinence following residential treatment for adolescents with substance use disorders. Addiction. 2006;102:81–93.CrossRef
23.
American Society of Addiction Medicine. ASAM PPC-2R- ASAM patient placement criteria for the treatment of substance-related disorders. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine; 2001. Revised.
24.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS): 2005. Discharges from Substance Abuse Treatment Services, DASIS Series: S-41, DHHS Publication No. (SMA) 08-4314. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2008.
25.
Rosenman MB, Holmes AM, Ackermann R, et al. The Indiana chronic disease management program. Milbank Q. 2006;84:135–63.PubMedCrossRef
26.
Project Match Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. J Stud Alcohol. 1997;58:7–29.
27.
Carroll KM. A cognitive-behavioral approach: treating cocaine addiction. Rockville, MD: National Institute on Drug Abuse; 1998. NIH publication 98-4308.
28.
Davidson L, O’Connell MJ, Tondora J, Lawless M, Evans AC. Recovery in serious mental illness: a new wine or just a new bottle? Prof Psychol Res Pract. 2005;36:480–7.CrossRef
29.
Monti PM, Abrams DB, Kadden RM, Cooney NL. Treating alcohol dependence: a coping skills training guide. New York, NY: Guilford Press; 1989.
30.
Rothman AJ. Toward a theory-based analysis of behavioral maintenance. Health Psychol. 2000;19 Suppl 1:64–9.PubMedCrossRef
31.
Institute of Medicine. Crossing the quality chasm: a new health system for the twenty-first century. Washington, DC: National Academy Press; 2001.
32.
Institute of Medicine. Improving the quality of health care for mental and substance-use conditions: Quality Chasm series. Washington, DC: National Academies Press; 2006.
33.
Harris AHS, McKellar JD, Moos RH, Schaefer JA, Cronkite RC. Predictors of engagement in continuing care following residential substance use disorder treatment. Drug Alcohol Depend. 2006;84:93–101.PubMedCrossRef
34.
McKay JR, Foltz C, Leahy P, Stephens R, Orwin R, Crowley E. Step down continuing care in the treatment of substance abuse: correlates of participation and outcome effects. Eval Program Plann. 2004;27:321–31.CrossRef
35.
Dennis ML, Scott CK, Funk R. An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. Eval Program Plann. 2003;26:339–52.CrossRef
36.
Scott CK, Dennis ML. Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction. 2009;104:959–71.PubMedCrossRef
37.
Morgenstern J, Blanchard KA, McCrady BS, McVeigh KH, Morgan TJ, Pandina RJ. Effectiveness of intensive case management for substance-dependent women receiving temporary assistance for needy families. Am J Public Health. 2006;96:2016–23.PubMedCrossRef
38.
Morgenstern J, Hogue A, Dauber S, Dasaro C, McKay JR. A practical clinical trial of care management to treat substance use disorders among public assistance beneficiaries. J Consult Clin Psychol. 2009;77:257–69.PubMedCrossRef
39.
Miller WR, Rollnick S. Motivational Interviewing: preparing people for change addictive behavior. 2nd ed. New York, NY: Guilford Press; 2002.
40.
McKay JR, Van Horn D, Oslin D, Lynch KG, Ivey M, Ward K, Drapkin M, Becher JR, Coviello D. A randomized trial of extended telephone-based continuing care for alcohol dependence: within treatment substance use outcomes. Journal of Consulting and Clinical Psychology, in press.
41.
Lynch KG, Van Horn D, Drapkin M, Ivey M, Coviello D, McKay JR. Moderators of response to extended telephone continuing care for alcoholism. Am J Health Behav. 2010;34(6):788–800.PubMedCrossRef
42.
Van Horn D, Ivey M, Drapkin M, Thomas T, Domis S, Abdalla O, Herd D, McKay JR. Impact of low level incentives on participation in an extended continuing care intervention. Drug and Alcohol Dependence, in press.
43.
Murphy SA, Lynch KG, McKay JR, Oslin DW, Ten Have TR. Developing adaptive treatment strategies in substance abuse research. Drug Alcohol Depend. 2007;88:S24–30.PubMedCrossRef
44.
Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction. 2006;101:192–203.PubMedCrossRef
45.
Prendergast M, Podus D, Finney J, Greenwell L, Roll J. Contingency management for treatment of substance use disorders: a meta-analysis. Addiction. 2006;101:1546–650.PubMedCrossRef
46.
Petry NM. A comprehensive guide to the application of contingency management procedures in clinical settings. Drug Alcohol Depend. 2000;58:9–26.PubMedCrossRef
47.
Shepard DS, Calabro JAB, Love CT, McKay JR, Tetreault J, Yeom HS. Counselor incentives to improve client retention in an outpatient substance abuse aftercare program. Adm Policy Ment Health. 2006;33:629–35.PubMedCrossRef
48.
Marlowe DB, Festinger DS, Arabia PL, Dugosh KL, Benasutti KM, Croft JR, et al. Adaptive interventions in drug court: a pilot experiment. Crim Justice Rev. 2008;33:343–60.PubMedCrossRef
49.
Brooner RK, Kidorf MS, King VL, Stoller KB, Peirce JM, Bigelow GE, et al. Behavioral contingencies improve counseling attendance in an adaptive treatment model. J Subst Abuse Treat. 2004;27:223–32.PubMedCrossRef
50.
Lash SJ, Burden JL, Fearer SA. Contracting, prompting, and reinforcing substance abuse treatment aftercare adherence. J Drug Addict Educ Erad. 2007;2:455–90.
51.
Miller WR, Weisner C. Integrated care. In: Miller WR, Weisner CM, editors. Changing substance abuse through health and social systems. New York, NY: Kluwer Academic/Plenum; 2002. p. 243–53.CrossRef
52.
Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med. 1999;159:1946–52.PubMedCrossRef
53.
Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addictions treatment: a randomized controlled trial. J Am Med Assoc. 2001;286:1715–23.CrossRef
54.
Milby JB, Schumacher JE, Wallace D, Frison J, McNamara C, Usdan S, et al. Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up. J Consult Clin Psychol. 2003;71:619–21.PubMedCrossRef
55.
Silverman K, Svikis D, Wong CJ, Hampton J, Stitzer ML, Bigelow GE. A reinforcement-based therapeutic workplace for the treatment of drug abuse: three-year abstinence outcomes. Exp Clin Psychopharmacol. 2002;10:228–40.PubMedCrossRef
56.
Timko C, DeBenedetti A, Billow R. Intensive referral to 12-step self-help groups and 6-month substance use disorder outcomes. Addiction. 2006;101:678–88.PubMedCrossRef
57.
Litt MD, Kadden RM, Kabela-Cormier E, Petry N. Changing network support for drinking: initial findings from the network support project. J Consult Clin Psychol. 2007;75:542–55.PubMedCrossRef
58.
Moos RH, Moos BS. Treated and untreated alcohol-use disorders: course and predictors of remission and relapse. Eval Rev. 2007;31:564–84.PubMedCrossRef
59.
Vaillant GE. A 60-year follow-up of alcoholic men. Addiction. 2003;98:1043–51.PubMedCrossRef