Transcript Alcohol Center Personnel - CTN Dissemination Library

Telephone Continuing Care
James R. McKay, Ph.D.
Center on the Continuum of Care in the Addictions
Department of Psychiatry
University of Pennsylvania
Philadelphia VA CESATE
Baltimore CTN Regional Dissemination Workshop
6.04.10
Topics to be Covered in the
Presentation
• What does research tell us about effective
continuing care?
• Potential role of the telephone in continuing care
• Initial evaluation of a telephone continuing care
protocol
– Was it effective?
– How did it work?
– Whom is it contraindicated for?
Topics, continued
• Development of current telephone continuing care
intervention
– Components
– Evaluation with alcohol dependent patients
• Ongoing work with cocaine dependent patients
– Methods to increase engagement and retention
– New project
• Final Conclusions
Factors that Confer Extended
Vulnerability to Relapse
• Biological
– Neurocognitive factors
– Genetic factors
• Behavioral
– Poor coping/life skills
– Interpersonal problems
• Environmental
– Poor social support for recovery
– High risk neighborhoods
• Co-occurring disorders
– Depression
– PTSD
Evidence on Extended Treatment
• In review of continuing care literature
(McKay, 2009), factors associated with
significant effects were:
– Planned TX durations of > 12 months
– More active efforts to deliver TX to patients
– More recent studies!
Challenge…..
• Finding a way to deliver extended
treatments that are:
– Effective
– Economical
– Feasible/practical
Advantages of the Telephone
• Potential to promote better long-term engagement
and participation because:
– Convenient for client
– Individualized attention
– Reduces stigma of weekly trips to the treatment
program
Evidence Supporting Therapeutic
Use of the Telephone
• Studies suggest the telephone can be effective in
delivering treatment:
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Addiction (Foote & Erfurt, 1991; McKay et al., 2005)
Smoking (Lichtenstein et al., 1996)
Depression (Baer et al., 1995; Simon et al., 2004)
OCD (Greist et al., 1998)
Panic and Anxiety (Rollman et al., 2005)
Bulimia (Hugo et al., 1999)
Cardiac care (Jerant et al., 2001; Riegel et al., 2002)
First Telephone Continuing Care
Research Study:
Telephone vs. Other Active Interventions
Design
• Patients:
– 359 graduates of 4-week IOP programs
– Alcohol and/or cocaine dependent
• Continuing care treatment conditions:
– Standard group counseling (STND)
– Individualized relapse prevention (RP)
– brief telephone-based counseling (TEL)
• Followed for 24 months
McKay et al., 2004, Journal of Consulting and Clinical Psychology
Total Abstinence Rates
80
70
% Abstinent
60
STND
RP
TEL
50
40
30
20
Tx Main Effect
TEL > STND
p< .05
10
0
3
6
9
12
15
Month
McKay et al., 2005, Archives of General Psychiatry
18
21
24
% Cocaine Positive
Cocaine Urine Toxicology
45
40
35
30
25
20
15
10
5
0
STND
RP
TEL
3
6
9
12
Month
McKay et al., 2005, Archives of General Psychiatry
18
24
Tx by Time Interaction
STND vs. TEL slope,
p = .05
RP vs. TEL slope,
p= .03
Mediation analyses
What Accounts for
Therapeutic Effect of
Telephone Continuing Care?
Mensinger et al., (2007) Journal of Consulting and Clinical Psychology
Treatment Condition Effect on Self-Help
Involvement
Tx Main Effect
3 months
TEL > STND
p < .05
Treatment Condition Effect on Self-Efficacy
Tx Main Effect
6 months
TEL > STND
p = .001
Treatment Condition Effect on
Commitment to Abstinence
Tx Main Effect
6 months
TEL > STND
p = .04
Mediation Models
• Based on Krull & MacKinnon (2001) approach
• 3 and 6 month score on mediators, controlling for
baseline values (i.e., end of IOP)
• Also controlled for substance use during
continuing care
• Significant mediation effects
– Self-help involvement (3 months)
– Self-efficacy and commitment to abstinence (6 months)
– Change in self-help predicted changes in self-efficacy
Is Telephone Continuing Care
Effective for All Patients?
7-Item Composite Risk Indicator
• Failure to achieve key goals while in IOP:
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Any alcohol use in prior 30 days
Any cocaine use in prior 30 days
Attendance at < 12 self-help meetings in prior 30 days
Social support < median for the sample
Does not have goal of absolute abstinence
Self-efficacy < 80%
• Current dependence on both alcohol and cocaine
(each item: yes=1, no=0)
McKay et al., 2005, Addiction, Archives of General Psychiatry
Distribution of Scores on the
Composite Risk Indicator
Number of Participants
120
100
Mean score= 2.50
80
60
40
20
0
0
1
2
3
4
5
Composite Risk Indicator Score
6
7
TEL vs. STND contrast X Risk Index Score: p < .05
Study Two:
Extended Telephone Continuing Care
vs. IOP Treatment as Usual
Design
• Patients: Patients with current alcohol dependence
recruited from IOPs after 3-4 weeks of treatment
(50% current/75% lifetime cocaine dependence)
• Treatment conditions:
– Treatment as usual (TAU)
– TAU plus TEL monitoring & feedback only
(TM; 18 months)
– TAU plus TEL monitoring and adaptive counseling
(TMAC; 18 mo.)
• Outcomes assessed over 24 months
• 252 randomized participants in the study
McKay et al. (in press). Journal of Consulting and Clinical Psychology
1019 IOP Patients Screened
• Reasons for exclusion (most common)
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No show for baseline interviews
No current ETOH dependence
Past 4 weeks in IOP
Not interested
Did not complete baseline
Severe psychiatric problems
IV heroin / opiate dependent
No phone
N=280
N=181
N=109
N=64
N=47
N=35
N=29
N=15
Content of Telephone Contacts
• Common ingredients of effective treatments
– Monitoring of symptoms and progress
– Identification of problems and barriers to
recovery
– Emphasis on concrete planning and problem
solving
– Activate the patient—take charge of own
recovery
The Telephone Calls
• Frequency: weekly at first, titrated to bimonthly
• Each call starts with a brief “progress assessment”
that assesses negative and positive factors and
yields overall risk score (low, moderate, high)
– Risk factors
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Failure to attend medical appointments
Depression
Low self-efficacy (low confidence in coping)
Craving or obsessive thoughts of using
In high risk situations
Telephone Calls, cont.
– Protective factors
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Good coping skills
Pro-recovery social activities
Having and working toward personal goals
Attending AA/NA meetings
Regular contact with a sponsor
– General status items
• Any alcohol or drug use
• IOP attendance status
Telephone Calls, cont.
• Structure and content of the calls:
1.
2.
3.
4.
5.
6.
7.
Provide feedback on risk level
Review progress/goals from last call
Identify upcoming high-risk situations
Select target for remainder of call
Brief problem-solving regarding target concern(s)
Set goal(s) for interval before next call
Suggest change in level of care if warranted
Who are the Telephone Counselors?
• Most are MA-level, with at least some experience
in addictions counseling
• Social workers have many skills that work well in
telephone continuing care
• Ability to engage patient, listen closely, be lively,
and set limits is important
• All sessions are audio-taped, which is used for
supervision and rating of adherence
Methods
• Follow-ups at 3, 6, 9, 12, 15, 18, 21, 24
months
• Follow-up rate over 80% out to 15 months,
79% out to 24 months
• Outcomes obtained with:
– TLFB
– Collateral reports
– Urine toxicology
Participation in Telephone Protocols
Percent Completing Orientation
100
90
80
70
60
50
40
30
20
10
0
Percent Possible Calls Completed
100
90
80
70
60
50
40
30
20
10
0
TM
TMAC
M=11
M=9
TM
TMAC
Adherence to Clinical Protocols
(% rated call with component present)
Tx Component
Risk Assessment
Feedback
Review Progress
ID High Risk Sit
Select Topic
RP/CBT Work
Set Goal for Week
TM
100.0
99.2
23.5
9.5
5.0
18.8
9.2
Note: 16% of all recorded calls rated
TMC
97.7
88.4
90.7
57.1
25.3
73.8
70.7
Results:
Alcohol Use Outcomes
Percent Days Alcohol Use
% Days Alcohol Use
70
60
50
TX condition x Time p=.025
40
30
*
*
20
***
+
10
**
TAU
TM
TMC
+
o
16
-1
8
m
o
m
5
13
-1
10
-1
2
m
o
m
o
9
7-
m
o
4-
6
m
o
3
1-
Ba
se
lin
e
0
TM<TAU; + p< .05
Assessment
McKay et al. (in press). JCCP
TMC< TAU: * p< .05; ** p= .004; *** p= .0002
% With Any Alcohol Use
Percent With Any Alcohol Use
60
50
40
TAU
TM
TMC
30
20
10
0
1-3 mo
4-6 mo
7-9 mo
10-12
mo
Assessment
13-15
mo
16-18
mo
TMC < TAU
p= .016
Percent Days Alcohol Use (Log)
Moderating Effect of Gender on Response to TM
4.5
4
3.5
3
2.5
2
1.5
TAU Male
TAU Fem
TM Male
TM Fem
1
0.5
0
TX x Gender
P= .002
B
3mo
6mo
9mo
12mo 15mo 18mo
Follow-up Period
Lynch et al. (in press). American Journal of Health Behavior
In women,
TM<TAU,
P= .006
Good Clinical Outcome
All Participants
GCO= < 1 day drinking/week, no heavy drinking days, no cocaine use, no positive urine drug screens,
no days of inpatient alcohol/drug treatment, no days inpatient psychiatric treatment
Participants with Low Motivation for Change
Participants with Poor Social Support
TMC>TAU, p= .02
Participants with Prior AOD Treatments
Extended Telephone-Based
Protocol for the Management of
Cocaine Dependence
Design
• Patients: Cocaine dependent IOP participants still
attending in week 2 (N=322)
• Treatment conditions:
– Treatment as usual (TAU)
– TAU plus telephone counseling for 24 mo. (TMC)
– TAU plus telephone counseling (24 mo.), plus
incentives for participation and cocaine-free urines
(first 12 mo) (TMC Plus)
• Outcomes assessed over 24 months
Screening and Recruitment
• Changes to inclusion/exclusion criteria
– Lifetime cocaine dependence, with some use in
last 6 months (current dx not required)
– Have completed 2 vs. 4 weeks of IOP treatment
– Less stringent requirements for ongoing
psychiatric follow-up of effected patients
• Result: much higher ratio of enrolled /
screened than in prior study
Changes to Clinical Protocol
• Lengthened face-to-face orientation to 2 sessions
• Added HIV risk reduction component to orientation
• Provided patients with choice of doing sessions over the
telephone or in person
• Greater focus on helping patient stay engaged in IOP,
while in that phase of care
• Modified risk assessment
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More conversational in format
Simpler rules for step up/down
Lateral as well as vertical adaptations
Clearer directions for case management activities
Incentives in TMAC-Plus
• Patients receive $10 gift coupon (Target, Walmart, local
grocery store chain) for each completed clinical contact
• One $10 bonus gift coupon provided for every 3
consecutive contacts completed
• Additional $10 gift coupon for cocaine free urine provided
during an in-person stepped care session (e.g., MI or CBT)
• Incentives provided only in year 1 of protocol
• Participants have to come to our research site to receive
gift coupons (University rules)
Impact of Incentives on Telephone
Continuing Care Participation
Percent Attending Orientation
Received Incentives
Percent Possible Calls Completed
Received Incentives
New Continuing Care Grant
• RC1 Challenge grant to test an “enhanced” version
of telephone continuing care
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Patients begin at intake
Incentives are provided for completed contacts
Cell phones provided if needed
Patient choice around form of service delivery
More aggressive linkage to social and recovery
supports
– Greater emphasis on development of recovery capital
– Much more aggressive outreach when patients
disappear
Conclusions
Conclusions
• In IOP graduates, telephone continuing care is at
least as effective as standard group counseling and
individualized relapse prevention for patients with
alcohol and/or cocaine dependence.
• Telephone continuing care appears to work in IOP
graduates by increasing participation in self-help,
and increasing self-efficacy and commitment to
abstinence
• Patients who make poor progress while in IOP
may require more intensive continuing care before
being put on the telephone
Conclusions, cont.
• The addition of extended, telephone-based
continuing care to longer IOPs appears to improve
outcomes for patients with alcohol dependence
• In alcohol patients, adding counseling to calls
produces stronger effects than monitoring/
feedback alone, relative to standard care
• Most effective disease management in patients
with poor social support, low motivation, prior
treatments
• In cocaine patients, adding incentives to TMC
dramatically increases participation rates
Limitations and Caveats
• Access to the telephone can vary considerably
• Without incentives, rates of extended participation
may be low. However, the intervention is still
effective
• When given choice, many participants attend
continuing care sessions in person, rather than
over the phone
Acknowledgements
• Funding from NIDA
– R01 DA020623
– K02-DA00361
• Funding from NIAAA
– R01 AA014850
– P01-AA016821
• Funding from VHA
Resources
• McKay, J.R. (2009). Treating substance use
disorders with adaptive continuing care.
Washington, DC: American Psychological
Association
• McKay, J.R., Van Horn, D., & Morrison, R.
(2010). Telephone continuing care for adults.
Center City, MN: Hazelden.
Thanks to Collaborators
• Penn and TRI
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Adam Brooks
John Cacciola
Deni Carise
Donna Coviello
Michelle Drapkin
Kevin Lynch
Tom McLellan
Dave Oslin
Debbie Van Horn
• Other Institutions
– Jon Morgenstern
(Columbia)
– Dan Kivlahan (U Wash)
– Susan Murphy (U Mich)
– Linda Collins (PSU)
– Don Shepard (Brandeis)
– Mike French (U Miami)
Contact Information
James R. McKay, Ph.D.
Center on the Continuum of Care in the Addictions
3440 Market St., Suite 370
Philadelphia, PA 19104
(215) 746-7704
[email protected]
Center website: http://www.med.upenn.edu/ccc/