Telephone Continuing Care

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 MD Office of Education and Training for Addiction Services 7.27.11

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 • Preliminary outcomes • 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 CareResearch 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 analysesWhat 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. Is Telephone Continuing Care Effective for All Patients?

18. 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

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

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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Telephone Calls, cont. • Structure and content of the calls: • Provide feedback on risk level • 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

28. 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

29. 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

30. Participation in Telephone Protocols Percent Completing Orientation Percent Possible Calls Completed M=11 M=9

31. Adherence to Clinical Protocols(% rated call with component present) Note: 16% of all recorded calls rated

32. Results:Alcohol Use Outcomes

33. Percent Days Alcohol Use TX condition x Time p=.025 *** * ** * + + TM<TAU; + p< .05 TMC< TAU: * p< .05; ** p= .004; *** p= .0002 McKay et al. (2010). JCCP

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

35. Moderating Effect of Gender on Response to TM TX x Gender P= .002 In women, TM<TAU, P= .006 Lynch et al. (2010). American Journal of Health Behavior

36. Good Clinical Outcome

37. 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

38. Participants with Low Motivation for Change McKay et al. (in press). Addiction

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

40. Participants with Prior AOD Treatments

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

42. 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

43. 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

44. 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

45. 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)

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

47. Cocaine Use Outcomes

48. Participants who became cocaine abstinent in first weeks of IOP

49. Participants who continued to use cocaine in first weeks of IOP

50. Participants who became alcohol abstinent in first weeks of IOP