Continuing Care for Cocaine Dependence Comprehensive 2-Year Outcomes
This report presents 2-year outcome data from an outpatient continuing care study in which cocaine-dependent patients (N = 132) were randomly assigned to either standard group counseling (STND) or individualized relapse prevention (RP). Data on cocaine outcomes during the 6-month treatment phase of the study were presented in an earlier report (J. R. McKay, A. I. Alterman, J. S. Cacciola, M. R. Rutherford, & C. P. O'Brien, 1997). In the present report, a continuing care condition main effect was obtained on only 1 of 8 outcome variables examined. However, patients who endorsed a goal of absolute abstinence on entering continuing care had better cocaine use outcomes in RP than in STND, whereas the opposite was the case for those with less stringent abstinence goals. In addition, patients with current cocaine or alcohol dependence on entering continuing care who received RP had better cocaine use outcomes in Months 1-6 and better alcohol use outcomes in Months 13-24 than those in STND.
Available from: Steven L. Proctor
- "Greater affiliation with AA during the continuing care phase of treatment, however, has been found to predict better long-term outcomes . Similarly, patients who endorsed a goal of absolute abstinence on entering continuing care have fared better from group relapse prevention programming than 12-step group therapy . Thus, although some evidence suggests that various specific continuing care treatment modalities have the potential to enhance outcomes with specific subgroups of patients based on specific individual difference and pretreatment demographic characteristics, a modality that is consistent with patient preference appears to possess the most value in terms of contributing to the overall efficacy of the program. "
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ABSTRACT: There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.
Available from: Deborah H A Van Horn
- "These findings are consistent with the results of an earlier continuing care study (McKay et al., 1999), which found that patients in a 4 week IOP who continued to use cocaine or alcohol during IOP benefited from a coping skills-based relapse prevention intervention, whereas those who achieved remission during that period did equally well in that intervention or standard care. Another recent study with cocaine dependent patients also found that abstinence status at or within a few days of intake could be used in an adaptive protocol to identify which patients would benefit from augmented treatment (Petry, Barry, Alessi, Rounsaville, & Caroll, 2012). "
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Study tested whether cocaine dependent patients using cocaine or alcohol at intake or in the first few weeks of intensive outpatient treatment would benefit more from extended continuing care than patients abstinent during this period. The effect of incentives for continuing care attendance was also examined.
Participants (N = 321) were randomized to treatment as usual (TAU), TAU and telephone monitoring and counseling (TMC), or TAU and TMC plus incentives (TMC+). The primary outcomes were (a) abstinence from all drugs and heavy alcohol use and (b) cocaine urine toxicology. Follow-ups were at 3, 6, 9, 12, 18, and 24 months.
Cocaine and alcohol use at intake or early in treatment predicted worse outcomes on both measures (ps ≤ .0002). Significant effects favoring TMC over TAU on the abstinence composite were obtained in participants who used cocaine (odds ratio [OR] = 1.95 [1.02, 3.73]) or alcohol (OR = 2.47 [1.28, 4.78]) at intake or early in treatment. A significant effect favoring TMC+ over TAU on cocaine urine toxicology was obtained in those using cocaine during that period (OR = 0.55 [0.31, 0.95]). Conversely, there were no treatment effects in participants abstinent at baseline and no overall treatment main effects. Incentives almost doubled the number of continuing care sessions received but did not further improve outcomes.
An adaptive approach for cocaine dependence in which extended continuing care is provided only to patients who are using cocaine or alcohol at intake or early in treatment improves outcomes in this group while reducing burden and costs in lower risk patients.
Available from: ncbi.nlm.nih.gov
- "(2) What is the relation between indicators of end-of-treatment outcome domains and a proxy for longer-term outcomes? Based on existing literature (Budney et al., 2000; Budney et al., 2006; Carroll et al., 1994; Higgins et al., 2000; McKay et al., 1999), we hypothesized that frequency of marijuana use and duration of continuous abstinence during treatment would be strongly related to longer-term outcome. (3) What is the effect size associated with these outcomes? "
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ABSTRACT: While several randomized controlled trials evaluating a range of treatments for cannabis use disorders have appeared in recent years, these have been marked by inconsistency in selection of primary outcomes, making it difficult to compare outcomes across studies.
With the aim of identifying meaningful and reliable outcome domains in treatment studies of cannabis use disorders, we evaluated multiple indicators of marijuana use, marijuana problems, and psychosocial functioning from two independent randomized controlled trials of behavioral treatments for cannabis use disorders (Ns=450 and 136).
Confirmatory factor analysis indicated that the best-fitting model of outcomes in both trials encompassed three distinct factors: frequency of marijuana use, severity of marijuana use, and psychosocial functioning. In both trials, frequency of marijuana use and longest period of abstinence during treatment were most strongly associated with outcome during follow-up. Using two categorical definitions of "clinically significant improvement," individuals who demonstrated improvement differed on most end-of-treatment and long-term outcomes from those who did not improve.
Results may guide future randomized controlled trials of treatments for cannabis use disorders in the collection of relevant end-of-treatment outcomes and encourage consistency in the reporting of outcomes across trials.
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