Reinforcement of Abstinence and Continuing Care in Substance Abuse Treatment
April 6, 2015 updated by: US Department of Veterans Affairs
Reinforcement of Abstinence and Attendance in Substance Abuse Treatment
The Contracts, Prompts, and Social Reinforcement (CPR) intervention was designed to address the continuing care adherence needs of veterans presenting for substance use disorder (SUD) treatment.
Final results of our recently completed HSR&D clinical trial suggest CPR meaningfully impacts aftercare adherence and abstinence rates.
However, CPR did not impact abstinence rates at earlier follow-up points, other important measures of treatment outcome, or AA/NA support group attendance.
Furthermore, the generalizability of CPR to other sites has not been established.
Thus, the intervention has been modified and pilot testing of this improved version of CPR, which includes contingent reinforcement of abstinence and improved prompting of AA/NA attendance (CPR+), shows promising results.
We are conducting a multi-site randomized clinical trial to examine the effectiveness of CPR+.
We recruited 183 veterans seeking residential treatment at the Salem and Jackson VAMCs.
Our primary hypothesis is that the CPR group will have higher 1-year abstinence rates compared to the STX group.
Our secondary hypotheses are that the CPR will be particularly effective for individuals with co-morbid psychiatric disorders, and that the CPR+ group will remain in AA/NA and in aftercare for a longer duration, have fewer days of substance use, fewer hospitalizations, and lower costs of care.
Treatment outcome will be measured 3-, 6-, and 12-months after participants enter treatment and compared to baseline levels.
The current study will seek to extend past findings to show longer-term effectiveness of the CPR+ intervention on continuing care adherence and greater impact on treatment outcome.
Dissemination and implementation efforts will be ongoing for this brief, inexpensive intervention, which offers an important means to improve participation and outcome for individuals seeking SUD treatment within the VAMC.
Data collection and analysis has been completed.
Study Overview
Status
Completed
Intervention / Treatment
Detailed Description
The Contracts, Prompts, and Social Reinforcement (CPR) intervention was designed to address the continuing care adherence needs of veterans presenting for substance use disorder (SUD) treatment.
Final results of our recently completed HSR&D clinical trial suggest CPR meaningfully impacts aftercare adherence and abstinence rates.
Among CPR participants, 55% met the VA's SUD continuity of care performance measure (attending at least 2 therapy sessions each month for 3 months), compared to 36% of those in standard treatment (STX).
On the primary outcome variable, 57% of the participants in the CPR condition were abstinent at the 1-year follow-up compared to 37% of those in STX.
Post hoc moderator analyses also indicate that the intervention was particularly effective for participants with co-morbid psychiatric disorders.
However, CPR did not impact abstinence rates at earlier follow-up points, other important measures of treatment outcome, or AA/NA support group attendance.
Furthermore, the generalizability of CPR to other sites has not been established.
Thus, the intervention has been modified and pilot testing of this improved version of CPR, which includes contingent reinforcement of abstinence and improved prompting of AA/NA attendance (CPR+), shows promising results.
We conducted a multi-site randomized clinical trial to examine the effectiveness of CPR+ with 2 specific goals: 1) to compare CPR+ to STX on adherence to continuing care (i.e., AA/NA participation and aftercare therapy) and 2) to assess its effect on treatment outcome.
We recruited 183 veterans seeking residential treatment at the Salem and Jackson VAMCs.
Our primary hypothesis is that the CPR group will have higher 1-year abstinence rates compared to the STX group.
Our secondary hypotheses are that the CPR will be particularly effective for individuals with co-morbid psychiatric disorders, and that the CPR+ group will remain in AA/NA and in aftercare for a longer duration, have fewer days of substance use, fewer hospitalizations, and lower costs of care.
Treatment outcome will be measured 3-, 6-, and 12-months after participants enter treatment and compared to baseline levels using the Form-90 Interview, the Addiction Severity Index (ASI), questionnaire responses, and substance use screens.
Treatment adherence will be measured using VA databases, medical records, therapist ratings, and questionnaire responses.
Abstinence rates will be analyzed using a logistic regression model in which the parameters of interest are estimated using Generalized Estimating Equations.
Secondary outcomes will be analyzed using both marginal and linear mixed-effects models as appropriate.
The current study sought to extend past findings to show longer-term effectiveness of the CPR+ intervention on continuing care adherence and greater impact on treatment outcome.
Dissemination and implementation efforts are ongoing for this brief, inexpensive intervention, which offers an important means to improve participation and outcome for individuals seeking SUD treatment within the VAMC.
Study Type
Interventional
Enrollment (Actual)
183
Phase
- Phase 2
Contacts and Locations
This section provides the contact details for those conducting the study, and information on where this study is being conducted.
Study Locations
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-
Mississippi
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Jackson, Mississippi, United States, 39216
- G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS
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-
Virginia
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Salem, Virginia, United States, 24153
- Salem VA Medical Center, Salem, VA
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-
Participation Criteria
Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.
Eligibility Criteria
Ages Eligible for Study
18 years and older (Adult, Older Adult)
Accepts Healthy Volunteers
No
Genders Eligible for Study
All
Description
Inclusion Criteria:
Participants were recruited from consecutive veterans who successful complete the 28-day SARRTP at the Salem VAMC and the 21-day SARRTP at the Jackson VAMC. Participants who are uninterested in aftercare, who have unstable housing or other factors that made aftercare participation difficult, will be included to maximize the generalizability of our results.
Exclusion Criteria:
Individuals who did not live within a 60-minute drive, and those who did not have transportation and a work schedule allowing attendance of aftercare were ineligible.
Study Plan
This section provides details of the study plan, including how the study is designed and what the study is measuring.
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
|---|---|
|
Experimental: Contracts, Prompts and Reinforcement arm
Participants were provided with contracting, prompting and reinforcement of continuing care attendance and substance use abstinence.
|
Contracting, prompting and reinforcement of continuing care and abstinence.
|
|
Active Comparator: Control Arm
Participants were provided with routine care- they did not receive contracting, prompting and reinforcement of continuing care attendance and substance use abstinence.
|
Routine residential treatment and orientation to continuing care.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Abstinence Rate (During the Preceding 90 Days) at 12 Months Follow-up Point as Assessed by the Form-90
Time Frame: Assessed at 12 months
|
Participants who were abstinent was assessed via Form-90 Interview (Form 90I) is a structured interview that assesses substance use and related behaviors over the previous 90 days employing a calendar-based follow-back method that provides continuous measures of substance use, and has good reliability.
Measures include days abstinent, days using alcohol, days using drugs, total number of standard drinks, and days of self help meeting attendance.
Briefer versions were constructed to collect data via telephone in instances when participants did not return for in-person interviews.
As a reliability check on participants' self-report, a collateral interview was employed when contacting informants.
Participants who denied use on the Form-90, but had a positive substance use screen were considered to be not abstinent for that follow-up point.
|
Assessed at 12 months
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Abstinence Rate (During the Preceding 90 Days) at 3- and 6-months Follow-up Point as Assessed by the Form-90
Time Frame: Assessed at 3 and 6 months
|
Participants who were abstinent was assessed via Form-90 Interview (Form 90I) is a structured interview that assesses substance use and related behaviors over the previous 90 days employing a calendar-based follow-back method that provides continuous measures of substance use, and has good reliability.
Measures include days abstinent, days using alcohol, days using drugs, total number of standard drinks, and days of self help meeting attendance.
Briefer versions were constructed to collect data via telephone in instances when participants did not return for in-person interviews.
As a reliability check on participants' self-report, a collateral interview was employed when contacting informants.
Participants who denied use on the Form-90, but had a positive substance use screen were considered to be not abstinent for that follow-up point.
|
Assessed at 3 and 6 months
|
|
Days Until First Use of Alcohol or Drugs
Time Frame: Baseline to 12 months
|
Baseline to 12 months
|
|
|
Aftercare Attendance
Time Frame: Assessed at 3-, 6-, 9-, and 12-months
|
Measures of aftercare attendance include: Percentage of participants who attended at least 1 aftercare session; percentage of participants who attended at least 2 aftercare sessions/month for at least 3, 6, 9 and 12 months; and percentage of participants who passed the VAMC's SUD continuity of care performance measure (a benchmark for retention of clients in aftercare for at least two visits each month for 3 months following initial treatment)
|
Assessed at 3-, 6-, 9-, and 12-months
|
|
Self-help Support Group Attendance
Time Frame: Assessed over the past 90 days at 3, 6 and 12 months, and cumulative over 1 year
|
Assessed over the past 90 days at 3, 6 and 12 months, and cumulative over 1 year
|
|
|
Days of Substance Abuse (Across the Prior 90 Days)
Time Frame: Assessed at Baseline, 3-, 6-, and 12-month follow-up
|
Assessed at Baseline, 3-, 6-, and 12-month follow-up
|
|
|
Rates of Hospitalization (Across the Prior 90 Days)
Time Frame: Assessed at Baseline, 3-, 6-, and 12-months
|
Number of days hospitalized for any reason per the previous 90 days
|
Assessed at Baseline, 3-, 6-, and 12-months
|
Collaborators and Investigators
This is where you will find people and organizations involved with this study.
Investigators
- Principal Investigator: Steven J Lash, PhD, Salem VA Medical Center, Salem, VA
Publications and helpful links
The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.
General Publications
- Lash SJ, Timko C, Curran GM, McKay JR, Burden JL. Implementation of evidence-based substance use disorder continuing care interventions. Psychol Addict Behav. 2011 Jun;25(2):238-51. doi: 10.1037/a0022608.
- Lash SJ, Burden JL, Parker JD, Stephens RS, Budney AJ, Horner RD, Datta S, Jeffreys AS, Grambow SC. Contracting, prompting and reinforcing substance use disorder continuing care. J Subst Abuse Treat. 2013 Apr;44(4):449-56. doi: 10.1016/j.jsat.2012.09.008. Epub 2012 Oct 31.
Study record dates
These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.
Study Major Dates
Study Start
March 1, 2007
Primary Completion (Actual)
June 1, 2009
Study Completion (Actual)
June 1, 2011
Study Registration Dates
First Submitted
February 6, 2006
First Submitted That Met QC Criteria
February 6, 2006
First Posted (Estimate)
February 8, 2006
Study Record Updates
Last Update Posted (Estimate)
April 24, 2015
Last Update Submitted That Met QC Criteria
April 6, 2015
Last Verified
July 1, 2014
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- IIR 03-267
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