1. 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 Baltimore CTN Regional Dissemination Workshop 6.04.10

2. 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?

3. 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 –New project Final Conclusions

4. 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

5. 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!

6. Challenge….. Finding a way to deliver extended treatments that are: –Effective –Economical –Feasible/practical

7. 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

8. 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)

9. First Telephone Continuing Care Research Study: Telephone vs. Other Active Interventions

10. 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

11. Total Abstinence Rates Tx Main Effect TEL > STND p<.05 McKay et al., 2005, Archives of General Psychiatry

12. Cocaine Urine Toxicology Tx by Time Interaction STND vs. TEL slope, p =.05 RP vs. TEL slope, p=.03 McKay et al., 2005, Archives of General Psychiatry

13. Mediation analyses What Accounts for Therapeutic Effect of Telephone Continuing Care? Mensinger et al., (2007) Journal of Consulting and Clinical Psychology

14. Treatment Condition Effect on Self-Help Involvement Tx Main Effect 3 months TEL > STND p <.05

15. Treatment Condition Effect on Self-Efficacy Tx Main Effect 6 months TEL > STND p =.001

16. Treatment Condition Effect on Commitment to Abstinence Tx Main Effect 6 months TEL > STND p =.04

17. Mediation Models Based on Krull & MacKinnon (2001) approach 3 and 6 month score on mediators, controlling for baseline values (i.e., end of IOP) Also controlled for substance use during continuing care Significant mediation effects –Self-help involvement (3 months) –Self-efficacy and commitment to abstinence (6 months) –Change in self-help predicted changes in self-efficacy

18. Is Telephone Continuing Care Effective for All Patients?

19. 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

20. Distribution of Scores on the Composite Risk Indicator Mean score= 2.50

21. TEL vs. STND contrast X Risk Index Score: p <.05

22. Study Two: Extended Telephone Continuing Care vs. IOP Treatment as Usual

23. 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. (in press). Journal of Consulting and Clinical Psychology

24. 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

25. 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

26. 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

27. 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

28. 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

29. Who are the Telephone Counselors? Most are MA-level, with at least some experience in addictions counseling Social workers have many skills that work well in telephone continuing care 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

30. 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

31. Participation in Telephone Protocols Percent Completing OrientationPercent Possible Calls Completed M=11 M=9

32. Adherence to Clinical Protocols (% rated call with component present) Tx ComponentTMTMC Risk Assessment 100.097.7 Feedback 99.288.4 Review Progress 23.590.7 ID High Risk Sit 9.557.1 Select Topic 5.025.3 RP/CBT Work 18.873.8 Set Goal for Week 9.270.7 Note: 16% of all recorded calls rated

33. Results: Alcohol Use Outcomes

34. Percent Days Alcohol Use TX condition x Time p=.025 * * *** ** TMC< TAU: * p<.05; ** p=.004; *** p=.0002 TM<TAU; + p<.05 ++ McKay et al. (in press). JCCP

35. Percent With Any Alcohol Use TMC < TAU p=.016

36. Moderating Effect of Gender on Response to TM TX x Gender P=.002 In women, TM<TAU, P=.006 Lynch et al. (in press). American Journal of Health Behavior

37. Good Clinical Outcome

38. 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

39. Participants with Low Motivation for Change

40. Participants with Poor Social Support TMC>TAU, p=.02

41. Participants with Prior AOD Treatments

42. Extended Telephone-Based Protocol for the Management of Cocaine Dependence

43. 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

44. 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

45. 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

46. 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)

47. Impact of Incentives on Telephone Continuing Care Participation Percent Attending Orientation Percent Possible Calls Completed Received Incentives

48. 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

49. Conclusions

50. 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

51. 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 In cocaine patients, adding incentives to TMC dramatically increases participation rates

52. 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 When given choice, many participants attend continuing care sessions in person, rather than over the phone

53. Acknowledgements Funding from NIDA –R01 DA020623 –K02-DA00361 Funding from NIAAA –R01 AA014850 –P01-AA016821 Funding from VHA

54. 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.

55. 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)

56. 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 mckay_j@mail.trc.upenn.edu Center website: http://www.med.upenn.edu/ccc/ttp://www.med.upenn.edu/ccc/