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

Baltimore CTN Regional Dissemination Workshop6.04.10

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?

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

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

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!

Challenge…..

• Finding a way to deliver extended treatments that are: – Effective– Economical– Feasible/practical

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

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)

First Telephone Continuing CareResearch Study:

Telephone vs. Other Active Interventions

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

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

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

Mediation analyses

What Accounts for Therapeutic Effect of

Telephone Continuing Care?

Mensinger et al., (2007) Journal of Consulting and Clinical Psychology

Treatment Condition Effect on Self-Help Involvement

Tx Main Effect 3 monthsTEL > STND p < .05

Treatment Condition Effect on Self-Efficacy

Tx Main Effect 6 monthsTEL > STND p = .001

Treatment Condition Effect on Commitment to Abstinence

Tx Main Effect 6 monthsTEL > STND p = .04

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

Is Telephone Continuing Care Effective for All Patients?

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

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

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

Study Two:

Extended Telephone Continuing Care vs. IOP Treatment as Usual

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

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

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

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

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

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

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

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

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

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

Results:

Alcohol Use Outcomes

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. (in press). JCCP

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

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. (in press). American Journal of Health Behavior

Good Clinical Outcome

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

Participants with Low Motivation for Change

Participants with Poor Social Support

TMC>TAU, p= .02

Participants with Prior AOD Treatments

Extended Telephone-Based Protocol for the Management of

Cocaine Dependence

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

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

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

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)

Impact of Incentives on Telephone Continuing Care Participation

Percent Attending Orientation Percent Possible Calls Completed

Received Incentives Received Incentives

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

Conclusions

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

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

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

Acknowledgements

• Funding from NIDA– R01 DA020623– K02-DA00361

• Funding from NIAAA– R01 AA014850 – P01-AA016821

• Funding from VHA

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.

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)

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/