Patients in the case management condition attended approximately 43% more continuing care sessions than those in standard care, and also had lower legal problem severity at 12 months. In the IP sample, receiving step down continuing care was not associated with better alcohol or crack cocaine use outcomes over the 36 month follow-up. Patients who received ACC were also significantly more likely to remain abstinent from marijuana over the 9 month follow-up than those in the control condition (41% vs. 26%, d= .32, p< .05). Perhaps still more important is the recognition that even with effective interventions, wide variation in patient response is still the rule rather than the exception. Conversely, some patients would be willing to attend treatment in specialty care sessions, but are unable to do so because of family responsibilities, transportation problems, and so forth. Couples relapse prevention sessions after behavioral marital therapy for male alcoholics: Outcomes during the three years after starting treatment. In the field of addiction treatment, the term continuing care has been used to indicate the stage of treatment that follows an initial episode of more intensive care. Increasing adherence to substance abuse aftercare group therapy. The https:// ensures that you are connecting to the Therefore, there is empirical evidence for each component of the intervention. First, interventions with a longer planned duration of therapeutic contact appear to hold an advantage over shorter interventions, although more carefully controlled research in this area is necessary. Patterson, MacPherson, and Brady (1997) conducted a study that tested the effect of a continuing care protocol that consisted of home visits provided by a psychiatric nurse over a one-year period. Developing adaptive treatment strategies in substance abuse research. Effectiveness of continuing care interventions for substanceabusers: Implications for the study of long-term treatment effects. Some self-report variables favored group format, Individual MET, CBT, or 12-step facilitation (12 weeks duration, with 12 sessions for CBT and TSF, and 4 sessions for MET), No group differences on two primary drinking outcome variables, 2 session/wk for 20 wks: 12-step focused group counseling vs. group plus individual relapse prevention (RP), No group differences on frequency of cocaine or heavy drinking days, or on five of six other outcome measures. Kristenson H, Ohlin H, Hulten-Nosslin MB, Trell E, Hood B. However, randomized studies that directly compare extended versus short versions of the same interventions are needed before any firm conclusions can be drawn regarding the impact of duration.

Patients who got the orientation were almost twice as likely to attend aftercare as the control condition (70% vs. 40%) and they attended twice as many aftercare sessions (mean of 3.0 vs. 1.4). Lieber and colleagues (2003) conducted a study of extended monitoring and counseling for 789 heavy drinkers with significant alcoholic liver disease. (2005) conducted a randomized study in the United Kingdom that compared standard group-based continuing care to an intervention referred to as Early Warning Signs of Relapse Prevention Training (EWSRPT), developed by Gorski (1995). Conversely, the average sample size was 164 in studies that did produce positive effects. The experimental condition was referred to as Assertive Continuing Care, or ACC. This comprehensive intervention includes a functional analysis of substance use behaviors, and skills training in a variety of areas including pro-recovery activities, relapse prevention, problem solving, communication, and so forth. However, there was considerable variability in patient response and room for improvements in participation rates and effectiveness.

Lash SJ, Burden JL, Fearer SA. Of the studies in which continuing care was provided for a minimum of 12 months, all three studies (100%) yielded significant effects favoring the extended intervention. Higher abstinence rates, better adjustment, lower addiction severity, lower readmission rates in TEL vs control. It is noteworthy that unlike Lash's prior studies, the experimental condition was compared to a more minimal control, rather than to the full package minus one or two components.

Therefore, patient preference needs to be taken seriously and not simply seen as indicative of resistance or denial. Weisner C, Mertens J, Parthasarathy S, et al. Results indicated that patients who received these additional components were more likely to attend aftercare (100% vs. 70%) and attended more aftercare sessions (4.38 vs. 2.35, p< .02, d= .80) than those who received the orientation and contract only, and they also had fewer hospital readmissions (5 in 21 participants vs. 15 in 20 participants). Flexible treatment strategies in chronic disease: Clinical and research implications. It is possible that intensity effects are moderated by other factors, such as length of the treatment and the severity of the patient population. Pettinati HM, Weiss RD, Miller WR, Donovan D, Ernst DB, Rounsaville BJ. No differences between the three conditions on four drinking outcome measures. These 20 studies are described in Table 1. Graham K, Annis HM, Brett PJY, Venesoen P. A controlled field trial of group versus individual cognitive-behavioral training for relapse prevention. Medical Management Treatment Manual: A Clinical Research Guide for Medically Trained Clinicians Providing Pharmacotherapy as Part of the Treatment for Alcohol Dependence. Lash and colleagues have been conducting a systematic program of research aimed at increasing attendance in continuing care (Lash, Burden, & Fearer, 2007). In the addictions field, there is growing interest in the development and implementation of treatment protocols and systems that address the full continuum of care, from detoxification to extended recovery monitoring (ASAM, 2001; Dennis, Scott, & Funk, 2003; Humphreys & Tucker, 2002; McKay, 2005; McLellan, Lewis, O'Brien, & Kleber, 2000; Simpson, 2004).

McLellan AT, Carise D, Kleber HD. The studies in Table 1 were classified according to whether or not a statistically significant treatment effect was obtained. On the other hand, there were some studies with higher rates of participation; for example, patients in the O'Farrell et al. 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.

Participants who received the extended intervention had fewer sick days, fewer hospital days, and lower mortality rates over the six year follow-up, compared to participants in the control condition, which consisted of an initial screening for feedback of GGT test results via letter, and invitations every two years to repeat the baseline GGT test. As a service to our customers we are providing this early version of the manuscript. More modest effects, though potentially clinically meaningful, would not likely reach statistical significance with sample sizes of 100 or less.

The continuing care condition also produced one-third the rate of uncontrolled use of the principal substance of abuse, compared to that in the control condition (odds ratio = .3). Lash SJ. Results indicated that the telephone condition produced better abstinence outcomes than standard group counseling, and better outcomes than CBT on several outcomes (e.g., cocaine urine toxicology, liver function measures indicative of heavy drinking). Patterson DG, MacPherson J, Brady NM.

Further investigations of the role of patient-therapist within-session interactions in the degree to which patients comply with stepped care and other adaptive changes.

Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Continuity of care practices and substance use disorder patients' engagement in continuing care. Terms of Use and Privacy Policy.

Notably, continuity of care practices during residential treatment did not predict retention in continuing care. In the other three studies, assignment to treatment condition was done on the basis of sequential cohorts and availability of the experimental condition.

Bennett GA, Withers J, Thomas PW, Higgins DS, Bailey J, Parry L, Davies E. A randomized trial of early warning signs relapse prevention training in the treatment of alcohol dependence.

The control condition was standard care at the facility, which consisted of review appointments at the hospital every 6 weeks. In: Galanter M, editor. The work of Lash et al. All were first admissions for alcohol dependence. Next, Lash and colleagues studied whether providing social reinforcement on top of the other intervention components further improved outcomes.

Rather, each approach involved taking the intervention to the patient, either by involving a spouse, visiting the home, or using the telephone to deliver the intervention. However, many of the 10 studies that did not yield positive findings also evaluated CBT or CBT-like interventions. The continuing care intervention (9 sessions over 6 months) was based on a coping skills approach as described by Monti, Abrams, Kadden, and Cooney (1989). Managing addiction as a chronic condition. None of the other approaches was included in enough studies to draw any conclusions about effectiveness. Moreover, neither naltrexone condition was more effective than 12 months of placebo (Krystal, Cramer, Krol, & Kirk, 2001). A number of studies have focused on identifying methods that can be used to increase engagement with and extended participation in standard continuing care approaches. Mensinger JL, Lynch KG, TenHave TR, McKay JR. Mediators of telephone-based continuing care for alcohol and cocaine dependence.

This site complies with the for trustworthy health information: Rates of completed continuing care intakes was 24% in the standard condition, 44% in the condition with incentives, and 76% in the condition with incentives and a staff escort. Goodley SH, Godley MD, Karvinen T, Slown LL. Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Most studies included widely used measures of alcohol or drug use, which were often confirmed with urines samples or collateral reports. Further information on many of these studies can be found in four earlier reviews (McKay, 2001a, 2001b, 2005, and 2006). Moreover, the intervention with social reinforcement produced higher rates of abstinence at 6 months, as well as better alcohol use outcomes, than the very active control condition (Lash, Burden, Monteleone, & Lehmann, 2004). One way to evaluate the meaning of this 50% success rate would be to conduct a meta-analysis, which would yield an estimate of the average magnitude and statistical significance of the differences between experimental and control conditions. These clinicians reported that differences between treatment conditions of 10-12 percentage points on dichotomous measures such as total abstinence or a biological indicator of alcohol or drug use were clinically significant.

The next 10 years will no doubt see a significant increase in the number of medications available to treat substance use disorders, and most likely greater use of these medications within continuing care models. Adaptive algorithms can also be used to determine when patients are doing well enough in their initial treatment intervention to be stepped down to less burdensome and costly interventions. In the IOP sample, patients who received continuing care did have less crack cocaine use in the first six months of the follow-up, but not after that point. There are a number of examples of adaptive disease management approaches in the addictions. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Combining behavioral and pharmacological components in adaptive treatment, Identification of length of time a patient should be doing well (or poorly) within a level of care before treatment can be stepped down (or up), Development of protocols to offer extended monitoring to those who do not want traditional, abstinence-oriented specialty care, Development of methods to conduct sequential randomization studies, in which non-responders are randomized two or more times to different treatment options, Incorporation of new technology to promote more frequent assessment of tailoring variables and more rapid modifications of treatment. Schmitz JM, Oswald LM, Jacks SD, Rustin T, Rhoades HM, Grabowski J. Relapse prevention treatment for cocaine dependence: Group vs. individual format. A second quasi-experimental study by our group (McKay et al., 2002) evaluated the relative effectiveness of two forms of publicly funded substance abuse treatment provided in Washington State: The full continuum (FC), in which clients receive approximately three weeks of inpatient treatment prior to outpatient care, and the partial continuum (PC), in which clients are admitted directly to outpatient treatment. University of Pennsylvania, Treatment Research Institute, Philadelphia VAMC, Philadelphia, PA 19104, USA, (215) 746-7704, (215) 746-7733 (FAX), ude.nnepu.crt.liam@j_yakcm.

One of the unique features of this study is that it is the only published experimental test of an adolescent continuing care intervention. Dennis ML, Scott CK, Funk R. An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. It is possible that the effectiveness of continuing care interventions could be further improved by the use of adaptive algorithms, which adjust treatment over time on the basis of changes in patients' symptoms and status. Some of this reflects stigma that is still associated with going to rehab. However, there is increasing recognition that many individuals simply do not like some aspects of traditional treatment programs, including the emphasis on total abstinence, pressure to embrace the AA program, reliance on group therapy, and so forth. At this point, there is convincing evidence that continuing care can be effective in sustaining the positive effects of the initial phase of care. In addition, assignment to condition was not by randomization; instead, the control condition was provided when the continuing care nurse could not take on new cases (e.g., sick leave, annual leave). These and other adaptive treatment studies in the addictions are reviewed in detail in a forthcoming publication (McKay, 2009).

The At this point, there are few if any such studies in the literature. The EWSRPT protocol is similar to cognitive-behavioral relapse prevention in several respects, but places more emphasis on identifying and addressing early signs of vulnerability to relapse, which under the Gorski model is a process that often unfolds over several weeks. The effect of type of aftercare follow-up on treatment outcome among alcoholics. Effects of halfway house placement on retention of patients in substance abuse aftercare. National Library of Medicine Specifically, greater efforts to coordinate care, connect the patient to resources, and provide continuity (i.e., retain same counselors or case managers in continuing care) predicted longer participation in continuing care, whereas efforts to maintain contact with patients after they left the first phase of treatment did not. Results from the studies summarized in Table 1 indicate that none of the continuing care studies focused on alcohol patients published prior to 1997 yielded a significant treatment condition effect, whereas four of five studies published since 1997 did find significant effects. Follow-up periods were generally long, with 75% of the studies following patients for eight months or more, and follow-up rates were relatively good. Not surprisingly, studies with minimal or no continuing care control conditions were somewhat more likely to yield a positive result (7 of 11, or 64%), compared to those with active continuing care comparison control conditions (3 of 9, or 33%). The change can involve augmenting current treatment, or switching to a different treatment entirely. McKay JR, Lynch KG, Shepard DS, Ratichek S, Morrison R, Koppenhaver J, Pettinati H. The effectiveness of telephone-based continuing care in the clinical management of alcohol and cocaine use disorders: 12 month outcomes. Studies with negative results were those in which no treatment group main effects were obtained on the primary substance use outcome measure(s), or mixed results were obtained, such as outcomes on one measure favored one group, whereas the opposite effect was obtained on the other specified primary substance use outcome measures. Evaluation of full vs. partial continuum of care in the treatment of publicly-funded substance abusers in Washington State. Social reinforcement of substance abuse aftercare group therapy attendance. Lash SJ, Petersen GE, O'Connor EA, Lehmann LP.

Moreover, many patientsperhaps the majoritydo not engage in standard continuing care when it is available to them (McKay, Foltz et al., 2004). higher in Exp; condition. In this setting, each medical visit is likely to be brief, but treatment can be individualized and addiction-related medications useful for maintenance (e.g. Substance Abuse and Mental Health Services Administration. How large must a treatment effect be before it matters to practioners? Many of these studies have been summarized in earlier reports (McKay, 2001a, 2001b, 2005, 2006). Scott CK, Dennis ML. Patients were randomized to receive standard primary and continuing care treatment, or standard treatment plus case management delivered during both primary and continuing care phases. It is worth noting that in studies that found statistically significant treatment effects, the magnitude of the effects was also of clear clinical significant, according to conventions established by Cohen (1988) and the findings in the survey of clinicians published by Miller and Manuel (2008). The frequency of home visits could be increased following a relapse or other serious problems. Although adaptive treatment models hold out considerable promise for improving participation and outcomes in continuing care, a number of important problems will require additional research over the next decade. The assessment can focus strictly on substance use (Dennis et al., 2003), or can include other indicators of risk. Second, the intervention is relatively low cost, and can be added to treatment as usualof any sortrelatively easily. In a first study (Lash, 1998), patients in an inpatient program were randomly assigned to either receive or not receive a 20 minute aftercare orientation session, which included a contract to attend aftercare. The sample included patients who started treatment in residential/inpatient programs (IP; N=134) and intensive outpatient programs (IOP; N=370). Increasing participation in substance abuse aftercare treatment.

Two of the more exciting developments in disease management in the addictions are the use of alternative service delivery sites and methods to deliver continuing care, and the introduction of adaptive treatment models. These protocols all involve assessing patient progress at regular intervals and adjusting treatment on the basis of scores on the measure(s) of progress. Results indicated that the telephone continuing care condition produced higher abstinence rates (50% vs. 24%, p= .02), better adjustment outcomes (p< .05), lower overall problem severity (as assessed by the Addiction Severity Index, p < .001), and lower readmission rates (9% vs. 38%, p< .005) over a 3 month follow-up than a no continuing care control group. Participants were opiate dependent patients who were completing a primary treatment episode, including residential care, detoxification from methadone maintenance, drug-free outpatient counseling, or half-way houses. Drinking outcomes in Y2 favored RP, USA: 67% male, Hong Kong: 100% male, 100% Chinese; all opiate addicts, Recovery training and self-help groups (RTSH; 3hrs/wk for 26 wks) vs. community referrals and/or individual counseling, Probability and extent of relapses and level of crime lower in RTSH than control; also employment rate higher in RTSH, Follow-up contacts (15-20 over 12 mo) plus standard continuing care vs. standard continuing care only, Better outcomes on 3 substance use related treatment and cost measures; in exp. These changes are being driven by a number of factors, including progressive leadership at the state and local level, greater open-mindedness and pragmatism among treatment providers, increasing insistence from all stake holders for better outcomes, and a series of influential publications that have pointed out the similarities between addiction and other chronic disorders and the limitations of the addiction treatment system as currently constituted (McLellan et al., 2000; McLellan et al., 2003). O'Farrell, Choquette, and Cutter (1998) studied the effect of providing couples behavioral marital therapy relapse prevention sessions to couples who had completed an initial course of behavioral marital therapy (BMT). There are only two published studies of the use of these medications within the context of a continuing care model.

Presented at the annual Research Society on Alcoholism meeting; July 2008; Washington DC. A recent study published by Miller and Manuel (2008) surveyed clinicians who were participating in the National Institute on Drug Abuse's Clinical Trials Network (CTN) to determine how large a treatment effect had to be in order for it to be considered clinically meaningful. McKay JR. McCarty D, DiLonardo J, Argeriou M. State substance abuse and mental health managed care evaluation program. This intervention was compared in a randomized study (McAuliffe, 1990) to a control condition that consisted of referrals to available continuing care services in the community and crisis intervention counseling from the study staff. Finally, mediation analyses indicated that the favorable effects of the telephone condition appeared to be at least in part due to the fact that it produced higher rates of self-help attendance during continuing care than group counseling, and higher levels of self-efficacy and commitment to abstinence during the subsequent three months (Mensinger, Lynch, TenHave, & McKay, 2007). Of the studies in which continuing care was provided for more than 3 months but less than 12 months, 4 of 9 studies (44%) yielded significant findings. 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. Dennis ML, Scott CK. Schaefer, Ingudomnukul, Harris, and Cronkite (2005) found that greater use of continuity of care practices by counselors and case managers during outpatient treatment predicted longer participation in subsequent continuing care. Goodley MD, Godley SH, Dennis ML, Funk RR, Passetti LL. Circles of Recovery: Self-Help Organizations for Addictions. Schmitt, Phibbs, and Piette (2003) found that patients who lived within 10 miles of a continuing care facility were 2.6 times more likely to seek treatment there following discharge from residential treatment than those who lived at least 50 miles from the facility. Murphy SA, Lynch KG, McKay JR, Oslin DW, Ten Have TR. However, several quasi-experimental studies are also reviewed. A study conducted in Sweden examined the effect of an extended intervention for middle-aged, heavy drinking men that consisted of brief visits with a physician every three months, and monthly visits with a nurse that included a test of GGT levels (Kristenson, Ohlin, Hulten-Nosslin, Trell, & Hood 1983). J Subst Abuse Treat. Treating alcohol dependence: A coping skills training guide. The intervention also produced better employment outcomes and self-reported criminal activity outcomes than the control condition. McAuliffe WE. Without a more systematic and detailed review of the methodological features of the studies, it is not possible to determine whether this trend is due to better interventions or better designed studies, or to both. Results indicated that clients in the FC had greater alcohol-, drug-, and legal-problem severity at intake than those in the PC, whereas medical- and employment-problem severity was greater in the PC. No group differences on relapse rate, AA attendance, or other outcomes, Low follow-up rate, and data obtained from counselors, not research staff, Skills training and networking activities (2/wk for 26 wks) plus TC vs. TC only, Skill level at 12 mo. Their program, which they called Recovery Training and Self-Help, consisted of professionally-led recovery training sessions, peer-led self-help styled meetings, and weekend recreational activity. Please separate country code and area/city code from local number using spaces or dashes. McKay JR, Donovan DM, McLellan AT, Krupski A, Hansten M, Stark KD, Geary K, Cecere J. New insights into the efficacy of naltrexone based on trajectory-based re-analyses of two negative clinical trials. J Behavioral Health Services and Research. Foote A, Erfurt JC. Progress is closely monitored with regular assessments, and if the patient is not improving as expected, a change is made to the treatment according to a decision tree that consists of a number of specific if---then statements. Among the studies that included patients with drug use disorders, two of six studies published prior to 2000 yielded significant treatment condition effects, whereas all four studies published after 2000 found significant effects. Brown BS, O'Grady K, Battjes RJ, Farrell EV. Adoption and implementation of new technologies in substance abuse treatment. Sannibale C, Hurkett P, Van Den Bossche E, O'Connor D, Zador D, Capus C, Gregory K, McKenzie M. Aftercare attendance and post-treatment functioning of severely substance dependent residential treatment clients. Before Brown, O'Grady, Battjes, and Farrell (2004) investigated the effectiveness of a continuing care intervention for criminal justice clients who had completed outpatient treatment. Aftercare associated with higher rates of abstinence from all drugs, less opiate use, and lower rates of weekly drug use. For example, 17 of 20 studies featured random assignment of patients to two or more conditions. A conceptual framework for drug treatment process and outcomes. Continuing care for cocaine dependence: Comprehensive 2-year outcomes. Participants were graduates of inpatient or residential treatment programs in 12 studies (60%), and graduates of outpatient treatment programs in five studies (25%). O'Malley SS, Rounsaville BJ, Farren C, et al. Landon BE, Wilson B, Gustafson D, Cleary P. Effects of a Quality Improvement Collaborative on the Outcome of Care of Patients with HIV Infection: The EQHIV Study.

Studies that yielded positive effects for more intensive interventions included the study of Gorski's Early Warning Signs of Relapse Prevention Training (Bennett et al., 2005), the structured continuing care model developed by Sannibale and colleagues (2003), the Brown et al. Social reinforcement of substance abuse treatment aftercare participation: Impact on outcome. Compared to those in the control condition, participants assigned to receive continuing care had less opiate use (OR= .26, p< .01), cocaine use (OR= .36, p< .05), any drug use (OR= .37, p< .01), and weekly drug use (OR= .20, p< .01). Most interventions were delivered at a treatment setting, although telephone counseling was used in five studies. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form.