Recent research has indicated that individuals with substance use disorders can benefit from continuing care interventions, which extend treatment beyond the 4–8 weeks of care that is typically provided in the initial, more intensive, phase of treatment.1–3
Continuing care helps address the chronic vulnerability to relapse experienced by most patients who enter treatment for substance use disorders, but rates of dropout tend to be high, and many patients receive little continuing care.4
Not surprisingly, continuing care interventions that incorporate more active efforts to deliver the intervention and have a planned duration of at least 12 months are more likely to produce significant treatment effects than are continuing care interventions without these features.5,6
Our group has been studying the effectiveness of using the telephone to provide extended continuing care to patients with substance use disorders. In an initial study, we found that telephone-based continuing care was more effective than both treatment as usual (ie, group counseling) and individual cognitive-behavioral relapse prevention for patients with alcohol and/or cocaine dependence who had completed 4-week intensive outpatient programs (IOPs) at a community setting and a Veterans Affairs Medical Center setting.6,7
The outcomes in this study were self-reported abstinence rates, cocaine urine toxicology, and liver function measures obtained over a 24-month follow-up. The content of the telephone calls consisted of several cognitive-behavioral therapy (CBT) components, including monitoring of substance use status and progress toward identified goals, identification of current and anticipated high-risk situations, and development and rehearsal of improved coping behaviors.8
The current study evaluated a new version of the telephone continuing care protocol, which was modified in several ways to better address the chronic nature of alcohol use disorders3
and to be more compatible with publicly funded outpatient treatment. First, the protocol was lengthened from 3 to 18 months, to provide extended recovery support. Second, each call began with a brief structured assessment of current risk and protective factors, which was used to determine the focus of the remainder of the session. As in the first version of the protocol, the intervention featured CBT techniques including monitoring of progress, identification of high-risk situations, and rehearsal of improved coping behaviors. Finally, we recruited patients after they had completed 3–4 weeks of treatment in the IOP, rather than at the point of graduation. This intervention is referred to as “telephone monitoring and counseling” (TMC).
In the study, TMC was compared to treatment as usual (TAU) (ie, up to 4 months of IOP without any telephone continuing care) and to a second telephone intervention that consisted of a brief assessment of current symptom severity and functioning plus feedback, but with no actual counseling (TM). Results from the 18-month period during which the telephone continuing care interventions were offered indicated that the best alcohol-use outcomes were in TMC.9
With percent days alcohol use, TMC produced less frequent drinking than TAU at 12 months (P<.02), 15 months (P=.0002), and 18 months (P=.004), and less frequent drinking than TM at 6 months (P=.02). TM produced less frequent drinking than TAU at 12 and 15 months (P=.03). With the dichotomous measure of any drinking within each 3-month segment of the follow-up, rates of drinking were lower in TMC than in TAU across the follow-up (P=.02), but there were no differences between TM and TAU (P=.42).
The purpose of this manuscript is to determine whether these main effect results were moderated by factors assessed at intake to treatment. In the case of TMC, such analyses can be used to determine whether there are certain types of patients who are particularly likely to benefit from the intervention. Although no significant main effects were found for the TM condition, moderation analyses might identify types of patients who do benefit from this intervention.
We hypothesized that the positive effects of extended continuing care would 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.8,10–13
These domains were represented with the following measures: years of regular alcohol use, years of heavy alcohol use, and number of prior treatments for alcohol problems (history); days of alcohol use, heavy alcohol use, and cocaine use during IOP (poor initial response to treatment); and craving levels, motivation for change, self-efficacy, and perceptions about the harm of continued substance use and potential benefits of treatment (additional relapse risk factors). We also examined the potential moderating effect of gender.