BACKGROUND/RATIONALE:
Although substance use disorder (SUD) treatment continuing care participation is strongly related to positive outcomes, participation rates are low and few effective adherence interventions have been developed.

OBJECTIVE(S):
This multi-site randomized clinical trial hypothesized that an enhanced version of Contracts, Prompts and Reinforcement (CPR+) compared to standard treatment (STX) would: 1) increase continuing care adherence, 2) increase 1-year abstinence rates, 3) demonstrate cost-effectiveness, 4) generalize across VA sites and 5) be particularly effective with participants with co-occurring psychiatric disorders.

METHODS:
Participants (n = 183) from the Salem and Jackson VAMCs were blocked on SUD diagnosis, presence of a co-occurring psychiatric disorder, and selected aftercare therapy group time prior to randomization to STX or CPR+ at each site. Participants were primarily African-American (54%) and Caucasian (44%) male (96%) veterans. Co-occurring psychiatric disorders were present in 62% of the sample, and 33% were alcohol dependent only while 67% were drug dependent. Treatment outcome was measured 3-, 6-, and 12-months after participants entered treatment. Abstinence rates were analyzed using a longitudinal logistic GEE (Generalized Estimating Equations) regression model. Secondary outcomes were analyzed using both logistic and linear mixed-effects models as appropriate.

FINDINGS/RESULTS:
We enrolled 102% of the projected number of participants and the follow-up rates were high. Among CPR+ participants,70% received at least 4 months of treatment compared to 58% of the STX group (p = .06). There was no significant change in the aftercare participation rate between groups over time during the 12 months of follow-up (p = .36). The average monthly rate (two or more sessions) was 51% for CPR+ and 44% for STX. Furthermore, the increase in the frequency of support group participation over 1 year was not significant (54.6 vs. 45.7; p = .17). Additionally, the CPR+ participants were not more likely than the STX group to be abstinent at the 3-month (67% vs. 71%; p =.52), 6-month (52% vs. 51%; p = .87), or 12-month interviews (48% vs. 49%; p = .68). The capital and labor cost of conducting CPR+ for one year was $266.54 per participant. The incremental cost compared to STX was $98.25 per participant. Data suggests that CPR+ was effective for individuals not required to attend continuing care. The effects of CPR+ were not moderated by site, co-occurring psychiatric disorder, or substance of abuse.

IMPACT:
The current trial demonstrated that CPR+ could be implemented at new VAMC sites, but it did not replicate the positive effects observed in previous trials. CPR+ did not significantly improve continuing care attendance, substance use outcomes, or quality of life compared to the STX group. A much higher percentage of participants in this trial compared to previous trials were required to attend aftercare. Results suggest that CPR+ was ineffective for those require to attend aftercare, but effective for those without this source of motivation. Additionally, findings suggest that changes to improve and adapt CPR+ to sites may have lessened its effectiveness in this trial.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. 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. Journal of substance abuse treatment. 2013 Apr 1; 44(4):449-56. [view]
2. Lash SJ, Timko C, Curran GM, McKay JR, Burden JL. Implementation of evidence-based substance use disorder continuing care interventions. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2011 Jun 1; 25(2):238-51. [view]

Conference Presentations

1. Lash SJ, Fearer SA, Burden JL. Contracting, Prompting and Reinforcing Substance Use Disorder Aftercare. Presented at: Carilion Clinic Research Conference; 2008 May 1; Roanoke, VA. [view]
2. Lash SJ, Burden JL, Parker JD, Stephens RS, Grambow SC, Budney AJ, Datta SK, Jeffreys AL, Horner RD. Contracting, Prompting and Reinforcing Substance Use Disorder Continuing Care. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2012 Nov 15; National Harbor, MD. [view]
3. Fearer SA, Lash SJ. Contracting, Prompting and Reinforcing SUD Aftercare Attendance and Treatment Outcome: A Pilot Study. Paper presented at: VA Mental Health Annual Conference; 2005 Sep 1; Mesa, AZ. [view]
4. Lash SJ, Burden JL. Contracting, Prompting and Reinforcing SUD Continuing Care. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 1; Baltimore, MD. [view]
5. Lash SJ, Burden JL, Parker JD, Williams D. Contracts, Prompts and Social Reinforcement (CPR): Implementation Facilitators and Barriers in Substance Abuse Treatment. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2012 Nov 1; Washington, DC. [view]
6. Burden JL, Parker JD, Lash SJ. Contracts, prompts, and reinforcement (CPR): Strategies for improving adherence to substance use disorder continuing care. Paper presented at: VA Mental Health Annual Conference; 2009 Jul 1; Washington, DC. [view]
7. Lash SJ, Burden JL. Development of a substance use disorder treatment adherence intervention. Presented at: Salem Research Institute Meeting; 2008 May 1; Salem, VA. [view]
8. Lash SJ, Parker JD, Burden JL. Dissemination of Contracting, Prompting and Reinforcing Substance Abuse Treatment Continuing Care. Poster session presented at: VA QUERI National Meeting; 2008 Dec 1; Phoenix, AZ. [view]
9. DeMarce JM, Lash SJ, Parker JD, Burke R, Grambow SJ. Predictive, Concurrent, and Discriminative Validity of the Structured Clinical Interview for DSM-IV (SCID) among Patients Seeking Treatment for Substance Abuse. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2009 Nov 1; New York, NY. [view]
10. Hartzler B, Lash SJ, Roll J. Vouchers, prizes, and clinic privileges as reinforcement for abstinence: A review of the efficacy of contingency management applications. Poster session presented at: College on Problems of Drug Dependence Annual Meeting; 2011 Jun 18; Hollywood, FL. [view]

DRA: Substance Use Disorders
DRE: none
Keywords: Addictive Disorders
MeSH Terms: none