telephone continuing care james r. mckay, ph.d. center on the continuum of care in the addictions...
TRANSCRIPT
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Telephone Continuing Care
James R. McKay, Ph.D.
Center on the Continuum of Care in the AddictionsDepartment of Psychiatry
University of Pennsylvania
Philadelphia VA CESATE
MD Office of Education and Training for Addiction Services7.27.11
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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?
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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
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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
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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!
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Challenge…..
• Finding a way to deliver extended treatments that are: – Effective– Economical– Feasible/practical
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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
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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)
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First Telephone Continuing CareResearch Study:
Telephone vs. Other Active Interventions
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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 monthsMcKay et al., 2004, Journal of Consulting and Clinical Psychology
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Total Abstinence Rates
0
10
20
30
40
50
60
70
80
3 6 9 12 15 18 21 24
Month
% A
bstin
ent STND
RP
TEL
Tx Main EffectTEL > STND p< .05
McKay et al., 2005, Archives of General Psychiatry
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Cocaine Urine Toxicology
0
5
10
15
20
25
30
35
40
45
3 6 9 12 18 24
Month
% C
ocai
ne P
ositi
ve
STND
RP
TEL
Tx by Time InteractionSTND vs. TEL slope, p = .05RP vs. TEL slope,p= .03
McKay et al., 2005, Archives of General Psychiatry
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Mediation analyses
What Accounts for Therapeutic Effect of
Telephone Continuing Care?
Mensinger et al., (2007) Journal of Consulting and Clinical Psychology
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Treatment Condition Effect on Self-Help Involvement
Tx Main Effect 3 monthsTEL > STND p < .05
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Treatment Condition Effect on Self-Efficacy
Tx Main Effect 6 monthsTEL > STND p = .001
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Treatment Condition Effect on Commitment to Abstinence
Tx Main Effect 6 monthsTEL > STND p = .04
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Is Telephone Continuing Care Effective for All Patients?
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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
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0
20
40
60
80
100
120
Nu
mb
er o
f P
arti
cip
ants
0 1 2 3 4 5 6 7Composite Risk Indicator Score
Distribution of Scores on the Composite Risk Indicator
Mean score= 2.50
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TEL vs. STND contrast X Risk Index Score: p < .05
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Study Two:
Extended Telephone Continuing Care vs. IOP Treatment as Usual
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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
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1019 IOP Patients Screened
• Reasons for exclusion (most common)– No show for baseline interviews N=280
– No current ETOH dependence N=181
– Past 4 weeks in IOP N=109
– Not interested N=64
– Did not complete baseline N=47
– Severe psychiatric problems N=35
– IV heroin / opiate dependent N=29
– No phone N=15
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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
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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
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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
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Telephone Calls, cont.
• Structure and content of the calls: 1. Provide feedback on risk level
2. Review progress/goals from last call
3. Identify upcoming high-risk situations
4. Select target for remainder of call
5. Brief problem-solving regarding target concern(s)
6. Set goal(s) for interval before next call
7. Suggest change in level of care if warranted
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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
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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
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Participation in Telephone Protocols
010203040506070
8090
100
TM TMAC0
10203040506070
8090
100
TM TMAC
Percent Completing Orientation Percent Possible Calls Completed
M=11
M=9
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Adherence to Clinical Protocols(% rated call with component present)
Tx Component TM TMCRisk Assessment 100.0 97.7Feedback 99.2 88.4Review Progress 23.5 90.7ID High Risk Sit 9.5 57.1Select Topic 5.0 25.3RP/CBT Work 18.8 73.8Set Goal for Week 9.2 70.7
Note: 16% of all recorded calls rated
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Results:
Alcohol Use Outcomes
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Percent Days Alcohol Use
0
10
20
30
40
50
60
70
Assessment
% D
ays
Alc
oh
ol U
se
TAUTMTMC
TX condition x Time p=.025
* ****
**
TMC< TAU: * p< .05; ** p= .004; *** p= .0002
TM<TAU; + p< .05
++
McKay et al. (2010). JCCP
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Percent With Any Alcohol Use
0
10
20
30
40
50
60
1-3 mo 4-6 mo 7-9 mo 10-12mo
13-15mo
16-18mo
Assessment
% W
ith
An
y A
lco
ho
l Use
TAUTMTMC
TMC < TAUp= .016
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Moderating Effect of Gender on Response to TM
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
B 3mo 6mo 9mo 12mo 15mo 18mo
Follow-up Period
Pe
rce
nt
Da
ys
Alc
oh
ol
Us
e (
Lo
g)
TAU Male
TAU Fem
TM Male
TM Fem
TX x GenderP= .002
In women, TM<TAU,P= .006
Lynch et al. (2010). American Journal of Health Behavior
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Good Clinical Outcome
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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
McKay et al. (in press). Addiction
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Participants with Low Motivation for Change
McKay et al. (in press). Addiction
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Participants with Poor Social Support
TMC>TAU, p= .02
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Participants with Prior AOD Treatments
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Extended Telephone-Based Protocol for the Management of
Cocaine Dependence
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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
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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
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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
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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)
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Impact of Incentives on Telephone Continuing Care Participation
Percent Attending Orientation Percent Possible Calls Completed
Received Incentives Received Incentives
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Cocaine Use Outcomes
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Participants who became cocaine abstinent in first weeks of IOP
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Participants who continued to use cocaine in first weeks of IOP
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Participants who became alcohol abstinent in first weeks of IOP
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Participants who continued to use alcohol in first weeks of IOP
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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
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Conclusions
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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
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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
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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.
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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
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Acknowledgements
• Funding from NIDA– R01 DA020623– K02-DA00361
• Funding from NIAAA– R01 AA014850 – P01-AA016821
• Funding from VHA
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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.
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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)
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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
Center website: http://www.med.upenn.edu/ccc/