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 MD Office of Education and Training for Addiction Services 7.27.11 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
Preliminary outcomes 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:
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 50 STND RP TEL 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
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 Is Telephone Continuing Care Effective for All Patients? 7-Item Composite Risk Indicator
Failure to achieve key goals while in IOP: 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. (2010). Journal of Consulting and Clinical Psychology 1019 IOP Patients Screened Reasons for exclusion (most common)
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 patienttake 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 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 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 were MA-level, with at least some
experience in addictions counseling 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
30 20 10 0 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 + 0 TM
Percent With Any Alcohol Use % 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 1 0.5 0 TAU Male TAU Fem TM Male TM Fem TX x Gender P= .002
B 3mo 6mo 9mo 12mo 15mo 18mo Follow-up Period Lynch et al. (2010). American Journal of Health Behavior
In women, TM
McKay et al. (in press). Addiction 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 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 Cocaine Use Outcomes Participants who became cocaine abstinent in first weeks of IOP Participants who continued to use cocaine in first weeks of IOP Participants who became alcohol abstinent in first
weeks of IOP Participants who continued to use alcohol in first weeks of IOP New Continuing Care Grant RC1 Challenge grant to test an enhanced version of telephone continuing care
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 Conclusions, cont. In cocaine patients, adding incentives to TMC dramatically increases participation rates Cocaine patients who were still using cocaine or alcohol immediately before IOP or in the first few weeks of IOP benefited to a greater degree from
extended telephone continuing care than those who had stopped cocaine and alcohol use. Not clear that higher participation rates in patients who received incentives translates into better drug use outcomes. 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 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
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]
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