Effectiveness of residential treatment services for veterans with substance use disorders: A propensity score matching evaluation.

BACKGROUND: Prior reviews of substance use disorder (SUD) treatment have found mixed support for residential level of care but are limited by methodology problems and the ethical concerns of randomizing patients with severe SUD to lower levels of care. METHODS: The present study is the first to use a large archival SUD residential sample with a matched comparison group and one-year follow-up period to examine the benefits of residential treatment provided to adults clinically assessed as warranting SUD residential care. We used propensity score matching in our sample (N = 6177) of veterans with a SUD who were screened and accepted for Veterans Affairs (VA) SUD residential treatment between January 1st, 2019 and June 30th, 2019. RESULTS: We found evidence that VA SUD residential treatment saves veteran lives with an average 66% all-cause mortality risk reduction during the study period (b = -1.09, exp(b) = 0.34, p <0.001). Medium-to-large residential pre- to post-treatment self-reported mental health and SUD symptom improvements (|SMDrobust| = 0.54-0.93) were sustained by one-year post-screening. These residential treatment improvements were significantly larger than estimated counterfactual outcomes across self-reported SUD and stress disorder symptoms at one-year post-screening (ps <0.001). We found mixed behavioral, service utilization, and other self-reported mental health outcomes. CONCLUSIONS: We conclude that VA SUD residential treatment is an effective level of care for veterans warranting residential care particularly for SUD symptom improvements and reductions in mortality risk.

History and current status of contingency management programs in the Department of Veterans Affairs.

OBJECTIVE: This article describes the Department of Veterans Affairs (VA) national implementation of contingency management within VA substance use disorder (SUD) treatment programs. METHODS: The rationale for implementing CM, role of VA leadership, and training and supervision procedures are detailed. The role of the Veterans Canteen Service (VCS) in sustaining the CM implementation through the donation of incentives is outlined. Updated outcomes from the primary program, CM to incentivize stimulant abstinence, are provided. Data presented were gathered from June 2011 to January 2023, from VA facilities across the country. RESULTS: More than 6000 Veterans from 119 VA facilities have received CM in a 12-week program in which two urine samples are obtained per week, with 92% of the samples negative for the targeted substance. Two other CM pilot projects are described. The first incentivizes adherence to injectable medications for opioid and alcohol use disorders, with over 580 veterans from 27 VA sites participating to date. The second incentivized smoking cessation in 312 patients from four sites. A new initiative in which CM is implemented in smaller community-based VA facilities through use of onsite prize cabinets is presented and the possibility of providing CM remotely in VA is discussed. CONCLUSIONS: It has proved feasible to implement abstinence CM and several other CM pilot programs at many VA facilities. Factors that contributed to the success of the VA CM rollout, challenges that were encountered along the way, and lessons learned that may facilitate wider use of CM outside VA are discussed.

Measurement-based care in Veterans Health Administration mental health residential treatment.

In 2016, the Veterans Health Administration (VHA) launched the Measurement-Based Care (MBC) in Mental Health Initiative to support the use of patient-reported outcome measures (PROMs) across mental health services to increase veteran engagement and promote collaborative treatment planning. The present study reported on the administrations of PROMs across all residential stays within the VHA's Mental Health Residential Rehabilitation Treatment Programs between October 1, 2018, and September 30, 2019 (N = 29,111). We subsequently explored a subsample of veterans attending substance use residential treatment during the same period who completed the Brief Addiction Monitor-Revised (BAM-R; Cacciola et al., 2013) at admission and discharge (n = 2,886) to determine the feasibility of using MBC data for program evaluation. The rate of residential stays with at least one PROM was 84.49%. We also identified moderate to large treatment effects on the BAM-R from admission to discharge (Robust Cohen's d = .76-1.60). There is frequent use of PROMs in VHA mental health residential treatment programs with exploratory analyses demonstrating significant improvements for veterans in substance use disorder residential treatment. Considerations for the appropriate use of PROMs in the context of MBC are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Management of Substance Use Disorders: Synopsis of the 2021 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: In August 2021, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of substance use disorders (SUDs). This synopsis summarizes key recommendations. METHODS: In March 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2015 VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 35 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. This synopsis presents the recommendations that were believed to be the most clinically impactful. RECOMMENDATIONS: The scope of the CPG is broad; however, this synopsis focuses on key recommendations for the management of alcohol use disorder, use of buprenorphine in opioid use disorder, contingency management, and use of technology and telehealth to manage patients remotely.

The limitations of hospital and law enforcement databases in characterizing the epidemiology of firearm injury.

BACKGROUND: Current data on the epidemiology of firearm injury in the United States are incomplete. Common sources include hospital, law enforcement, consumer, and public health databases, but each database has limitations that exclude injury subgroups. By integrating hospital (inpatient and outpatient) and law enforcement databases, we hypothesized that a more accurate depiction of the totality of firearm injury in our region could be achieved. METHODS: We constructed a collaborative firearm injury database consisting of all patients admitted as inpatients to the regional level 1 trauma hospital (inpatient registry), patients treated and released from the emergency department (ED), and subjects encountering local law enforcement as a result of firearm injury in Jefferson County, Kentucky. Injuries recorded from January 1, 2016, to December 31, 2020, were analyzed. Outcomes, demographics, and injury detection rates from individual databases were compared with those of the combined collaborative database and compared using χ2 testing across databases. RESULTS: The inpatient registry (n = 1,441) and ED database (n = 1,109) were combined, resulting in 2,550 incidents in the hospital database. The law enforcement database consisted of 2,665 patient incidents, with 2,008 incidents in common with the hospital database and 657 unique incidents. The merged collaborative database consisted of 3,207 incidents. In comparison with the collaborative database, the inpatient, total hospital (inpatient and ED), and law enforcement databases failed to include 55%, 20%, and 17% of all injuries, respectively. The hospital captured nearly 94% of survivors but less than 40% of nonsurvivors. Law enforcement captured 93% of nonsurvivors but missed 20% of survivors. Mortality (11-26%) and injury incidence were markedly different across the databases. DISCUSSION: The utilization of trauma registry or law enforcement databases alone do not accurately reflect the epidemiology of firearm injury and may misrepresent areas in need of greater injury prevention efforts. LEVEL OF EVIDENCE: Epidemiological, level IV.

Accessibility to Medication for Opioid Use Disorder After Interventions to Improve Prescribing Among Nonaddiction Clinics in the US Veterans Health Care System.

Importance: With increasing rates of opioid use disorder (OUD) and overdose deaths in the US, increased access to medications for OUD (MOUD) is paramount. Rigorous effectiveness evaluations of large-scale implementation initiatives using quasi-experimental designs are needed to inform expansion efforts. Objective: To evaluate a US Department of Veterans Affairs (VA) initiative to increase MOUD use in nonaddiction clinics. Design, Setting, and Participants: This quality improvement initiative used interrupted time series design to compare trends in MOUD receipt. Primary care, pain, and mental health clinics in the VA health care system (n = 35) located at 18 intervention facilities and nonintervention comparison clinics (n = 35) were matched on preimplementation MOUD prescribing trends, clinic size, and facility complexity. The cohort of patients with OUD who received care in intervention or comparison clinics in the year after September 1, 2018, were evaluated. The preimplementation period extended from September 1, 2017, through August 31, 2018, and the postimplementation period from September 1, 2018, through August 31, 2019. Exposures: The multifaceted implementation intervention included education, external facilitation, and quarterly reports. Main Outcomes and Measures: The main outcomes were the proportion of patients receiving MOUD and the number of patients per clinician prescribing MOUD. Segmented logistic regression evaluated monthly proportions of MOUD receipt 1 year before and after initiative launch, adjusting for demographic and clinical covariates. Poisson regression models examined yearly changes in clinician prescribing over the same time frame. Results: Overall, 7488 patients were seen in intervention clinics (mean [SD] age, 53.3 [14.2] years; 6858 [91.6%] male; 1476 [19.7%] Black, 417 [5.6%] Hispanic; 5162 [68.9%] White; 239 [3.2%] other race [including American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and multiple races]; and 194 [2.6%] unknown) and 7558 in comparison clinics (mean [SD] age, 53.4 [14.0] years; 6943 [91.9%] male; 1463 [19.4%] Black; 405 [5.4%] Hispanic; 5196 [68.9%] White; 244 [3.2%] other race; 250 [3.3%] unknown). During the preimplementation year, the proportion of patients receiving MOUD in intervention clinics increased monthly by 5.0% (adjusted odds ratio [AOR], 1.05; 95% CI, 1.03-1.07). Accounting for this preimplementation trend, the proportion of patients receiving MOUD increased monthly by an additional 2.3% (AOR, 1.02; 95% CI, 1.00-1.04) during the implementation year. Comparison clinics increased by 2.6% monthly before implementation (AOR, 1.03; 95% CI, 1.01-1.04), with no changes detected after implementation. Although preimplementation-year trends in monthly MOUD receipt were similar in intervention and comparison clinics, greater increases were seen in intervention clinics after implementation (AOR, 1.04; 95% CI, 1.01-1.08). Patients treated with MOUD per clinician in intervention clinics saw greater increases from before to after implementation compared with comparison clinics (incidence rate ratio, 1.50; 95% CI, 1.28-1.77). Conclusions and Relevance: A multifaceted implementation initiative in nonaddiction clinics was associated with increased MOUD prescribing. Findings suggest that engagement of clinicians in general clinical settings may increase MOUD access.

Clinical leaders and providers' perspectives on delivering medications for the treatment of opioid use disorder in Veteran Affairs' facilities.

BACKGROUND: Improving access to medication treatment of opioid use disorder (MOUD) is a national priority, yet common modifiable barriers (e.g., limited provider knowledge, negative beliefs about MOUD) often challenge implementation of MOUD delivery. To address these barriers, the VA launched a multifaceted implementation intervention focused on planning and educational strategies to increase MOUD delivery in 18 medical facilities. The purpose of this investigation was to determine if a multifaceted intervention approach to increase MOUD delivery changed providers' perceptions about MOUD over the first year of implementation. METHODS: Cross-disciplinary teams of clinic providers and leadership from primary care, pain, and mental health clinics at 18 VA medical facilities received invitations to complete an anonymous, electronic survey prior to intervention launch (baseline) and at 12- month follow-up. Responses were summarized using descriptive statistics, and changes over time were compared using regression models adjusted for gender and prescriber status, and clustered on facility. Responses to open-ended questions were thematically analyzed using a template analysis approach. RESULTS: Survey response rates at baseline and follow-up were 57.1% (56/98) and 50.4% (61/121), respectively. At both time points, most respondents agreed that MOUD delivery is important (94.7 vs. 86.9%), lifesaving (92.8 vs. 88.5%) and evidence-based (85.2 vs. 89.5%). Over one-third (37.5%) viewed MOUD delivery as time-consuming, and only 53.7% affirmed that clinic providers wanted to prescribe MOUD at baseline; similar responses were seen at follow-up (34.5 and 52.4%, respectively). Respondents rated their knowledge about OUD, comfort discussing opioid use with patients, job satisfaction, ability to help patients with OUD, and support from colleagues favorably at both time points. Respondents' ratings of MOUD delivery filling a gap in care were high but declined significantly from baseline to follow-up (85.7 vs. 73.7%, p < 0.04). Open-ended responses identified implementation barriers including lack of support to diagnose and treat OUD and lack of time. CONCLUSIONS: Although perceptions about MOUD generally were positive, targeted education and planning strategies did not improve providers' and clinical leaders' perceptions of MOUD over time. Strategies that improve leaders' prioritization and support of MOUD and address time constraints related to delivering MOUD may increase access to MOUD in non-substance use treatment clinics.

Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: Expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities.

The US is confronted with a rise in opioid use disorder (OUD), opioid misuse, and opioid-associated harms. Medication treatment for opioid use disorder (MOUD)-including methadone, buprenorphine and naltrexone-is the gold standard treatment for OUD. MOUD reduces illicit opioid use, mortality, criminal activity, healthcare costs, and high-risk behaviors. The Veterans Health Administration (VHA) has invested in several national initiatives to encourage access to MOUD treatment. Despite these efforts, by 2017, just over a third of all Veterans diagnosed with OUD received MOUD. VHA OUD specialty care is often concentrated in major hospitals throughout the nation and access to this care can be difficult due to geography or patient choice. Recognizing the urgent need to improve access to MOUD care, in the Spring of 2018, the VHA initiated the Stepped Care for Opioid Use Disorder, Train the Trainer (SCOUTT) Initiative to facilitate access to MOUD in VHA non-SUD care settings. The SCOUTT Initiative's primary goal is to increase MOUD prescribing in VHA primary care, mental health, and pain clinics by training providers working in those settings on how to provide MOUD and to facilitate implementation by providing an ongoing learning collaborative. Thirteen healthcare providers from each of the 18 VHA regional networks across the VHA were invited to implement the SCOUTT Initiative within one facility in each network. We describe the goals and initial activities of the SCOUTT Initiative leading up to a two-day national SCOUTT Initiative conference attended by 246 participants from all 18 regional networks in the VHA. We also discuss subsequent implementation facilitation and evaluation plans for the SCOUTT Initiative. The VHA SCOUTT Initiative could be a model strategy to implement MOUD within large, diverse health care systems.

Steps for implementing measurement-based care: Implementation planning guide development and use in quality improvement.

Although the benefits of measurement-based care (MBC) are widely noted, MBC remains underutilized in mental health services. In 2016, the Department of Veterans Affairs, Veterans Health Administration began the MBC in Mental Health Initiative to implement MBC as a standard of care across VHA mental health services. Subsequently, in January 2018 The Joint Commission (TJC) revised their behavioral health care standards to require implementation of MBC. Based on key informant interviews with early adopters across VHA, we developed an MBC Implementation Planning Guide to support implementation of MBC in diverse mental health settings. In this article, we present the MBC Implementation Planning Guide, describe how it was developed, and suggest a process for its use by implementation teams within an overall quality improvement framework to support implementation of MBC consistent with local context and TJC requirements. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Barriers and Facilitators to Implementation of Pharmacotherapy for Opioid Use Disorders in VHA Residential Treatment Programs.

OBJECTIVE: Despite evidence of effectiveness, pharmacotherapy-methadone, buprenorphine, or naltrexone-is prescribed to less than 35% of Veterans Health Administration (VHA) patients diagnosed with opioid use disorder (OUD). Among veterans whose OUD treatment is provided in VHA residential programs, factors influencing pharmacotherapy implementation are unknown. We examined barriers to and facilitators of pharmacotherapy for OUD among patients diagnosed with OUD in VHA residential programs to inform the development of implementation strategies to improve medication receipt. METHOD: VHA electronic health records and program survey data were used to describe pharmacotherapy provided to a national cohort of VHA patients with OUD in residential treatment programs (N = 4,323, 6% female). Staff members (N = 63, 57% women) from 44 residential programs (response rate = 32%) participated in interviews. Barriers to and facilitators of pharmacotherapy for OUD were identified from transcripts using thematic analysis. RESULTS: Across all 97 residential treatment programs, the average rate of pharmacotherapy for OUD was 21% (range: 0%-67%). Reported barriers included provider or program philosophy against pharmacotherapy, a lack of care coordination with nonresidential treatment settings, and provider perceptions of low patient interest or need. Facilitators included having a prescriber on staff, education and training for patients and staff, and support from leadership. CONCLUSIONS: Contrary to our hypothesis, barriers to and facilitators of pharmacotherapy for OUD in VHA residential treatment programs were consistent with prior research in outpatient settings. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VHA providers, may help improve receipt of pharmacotherapy for OUD.

Outpatient continuing care after residential substance use disorder treatment in the US Veterans Health Administration: Facilitators and challenges.

BACKGROUND: In the U.S. Veterans Health Administration (VHA), residential treatment programs are an important part of the continuum of care for patients with substance use disorders (SUDs). Outpatient continuing care after residential treatment helps maintain early recovery and treatment gains. Knowing more about the drivers of variation in continuing care practices and performance across residential programs might inform quality improvement efforts. METHODS: Metrics of continuing care were operationalized and calculated for each of VHA's 63 SUD Residential Rehabilitation Treatment Programs (SUD RRTPs) and 34 Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) with a SUD track in fiscal year 2012. Management and frontline staff of these programs were then interviewed to learn what factors might contribute to high or low program performance on the metrics compared with national averages. RESULTS: Among SUD RRTPs, the mean rate of outpatient SUD/MH continuing care was 59% within 7 days and 80% within 30 days, and the mean rate of SUD continuing care was 63% within 30 days. Among MH RRTPs with a SUD track, these rates were 56%, 75%, and 36%, respectively. There was substantial variability in continuing care rates across the 97 programs: 21%-93% for SUD/MH care within 7 days, 36%-100% for SUD/MH care within 30 days, and 4%-91% for SUD care within 30 days. Interviews with representatives of 44 programs revealed key facilitators of continuing care: accountability of program staff, predischarge scheduling, predischarge introductions to continuing care providers, strong patient relationships, accessibility, and persistent emphasis. Key challenges included inadequate program staffing, lack of program staff accountability, and poor accessibility. CONCLUSIONS: Wide variation in continuing care rates across programs and identification of common facilitators at high-performing programs suggest substantial opportunity for improvement for programs with lower performance.

Barriers to and facilitators of pharmacotherapy for alcohol use disorder in VA residential treatment programs.

Among US military veterans, alcohol use disorder (AUD) is prevalent and in severe cases patients need intensive AUD treatment beyond outpatient care. The Department of Veterans Affairs (VA) delivers intensive, highly structured addiction and psychosocial treatment through residential programs. Despite the evidence supporting pharmacotherapy among the effective treatments for AUD, receipt of these medications (e.g., naltrexone, acamprosate) among patients in residential treatment programs varies widely. In order to better understand this variation, the current study examined barriers and facilitators to use of pharmacotherapy for AUD among patients in VA residential treatment programs. Semi-structured qualitative interviews with residential program management and staff were conducted and the Consolidated Framework for Implementation Research was used to guide coding and analysis of interview transcripts. Barriers to use of pharmacotherapy for AUD included cultural norms or philosophy against prescribing, lack of access to willing prescribers, lack of interest from leadership, and perceived lack of patient interest or need. Facilitators included cultural norms of openness or active promotion of pharmacotherapy; education for patients, program staff and prescribers; having prescribers on staff, and care coordination within residential treatment and with other clinic settings in and outside VA. Developing and testing improvement strategies to increase care coordination and consistent support from leadership may also yield increases in the use of pharmacotherapy for AUD among residential patients.

VA residential substance use disorder treatment program providers' perceptions of facilitators and barriers to performance on pre-admission processes.

BACKGROUND: In the U.S. Department of Veterans Affairs (VA), residential treatment programs are an important part of the continuum of care for patients with a substance use disorder (SUD). However, a limited number of program-specific measures to identify quality gaps in SUD residential programs exist. This study aimed to: (1) Develop metrics for two pre-admission processes: Wait Time and Engagement While Waiting, and (2) Interview program management and staff about program structures and processes that may contribute to performance on these metrics. The first aim sought to supplement the VA's existing facility-level performance metrics with SUD program-level metrics in order to identify high-value targets for quality improvement. The second aim recognized that not all key processes are reflected in the administrative data, and even when they are, new insight may be gained from viewing these data in the context of day-to-day clinical practice. METHODS: VA administrative data from fiscal year 2012 were used to calculate pre-admission metrics for 97 programs (63 SUD Residential Rehabilitation Treatment Programs (SUD RRTPs); 34 Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) with a SUD track). Interviews were then conducted with management and front-line staff to learn what factors may have contributed to high or low performance, relative to the national average for their program type. We hypothesized that speaking directly to residential program staff may reveal innovative practices, areas for improvement, and factors that may explain system-wide variability in performance. RESULTS: Average wait time for admission was 16 days (SUD RRTPs: 17 days; MH RRTPs with a SUD track: 11 days), with 60% of Veterans waiting longer than 7 days. For these Veterans, engagement while waiting occurred in an average of 54% of the waiting weeks (range 3-100% across programs). Fifty-nine interviews representing 44 programs revealed factors perceived to potentially impact performance in these domains. Efficient screening processes, effective patient flow, and available beds were perceived to facilitate shorter wait times, while lack of beds, poor staffing levels, and lengths of stay of existing patients were thought to lengthen wait times. Accessible outpatient services, strong patient outreach, and strong encouragement of pre-admission outpatient treatment emerged as facilitators of engagement while waiting; poor staffing levels, socioeconomic barriers, and low patient motivation were viewed as barriers. CONCLUSIONS: Metrics for pre-admission processes can be helpful for monitoring residential SUD treatment programs. Interviewing program management and staff about drivers of performance metrics can play a complementary role by identifying innovative and other strong practices, as well as high-value targets for quality improvement. Key facilitators of high-performing facilities may offer programs with lower performance useful strategies to improve specific pre-admission processes.

Pre-Implementation Review of Contracts, Prompts, and Reinforcement in SUD Continuing Care.

The Contracts, Prompts, and Reinforcement (CPR) intervention has demonstrated an ability to increase the duration of continuing care participation following substance use disorder (SUD) treatment, resulting in improved treatment outcome. The current project was a qualitative pre-implementation study aimed at identifying barriers and facilitators to implementation of CPR using an evidence-based quality improvement (EBQI) approach. Formative evaluations were conducted with staff from residential SUD treatment programs across three VA sites, and key informant interviews were completed with opinion and program leaders. Data were analyzed using a grounded theory approach, which identified barriers and facilitators to implementation. Fidelity measures were developed for each of the core CPR components, and the research-focused treatment manual was rewritten to facilitate future implementation efforts with the design and content of the documents shaped by the findings of the qualitative analyses. Overall, data suggested that clinicians and administrators are receptive to the core components of CPR.

Contracting, prompting and reinforcing substance use disorder continuing care.

The contracting, prompting and reinforcing (CPR) aftercare intervention has improved treatment adherence and outcomes in a number of clinical trials. In multisite randomized clinical trial 92 graduates of two intensive substance use disorder programs who received CPR were compared to 91 who received standard treatment (STX). The CPR group evidenced increased frequency of aftercare group therapy attendance and near significant findings suggested that more CPR than STX participants completed 3 months (76 vs. 64%), 6 months (48 vs. 35%), and 9 months (35 vs. 22%) of aftercare. However, the groups did not differ on the majority of attendance measures and had similar abstinence rates at the 3-month (67% CPR vs. 71% STX), 6-month (52% CPR vs. 51% STX), and 12-month (the primary outcome measure; 48% CPR vs. 49% STX) follow-up points. Exploratory analyses suggest that CPR might be more effective among participants not required to attend aftercare. The incremental capital and labor cost of CPR compared to STX was $98.25 per participant.

Implementation of evidence-based substance use disorder continuing care interventions.

Continuing care following initial substance use disorder treatment often is associated with improved treatment outcomes and evidence-based interventions (EBIs) have been developed in this area. However, rates of patient participation in continuing care treatment and mutual help groups (MHGs) are low and a large gap exists between the existing EBIs and actual clinical care. This paper uses the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) to review the literature on continuing care treatment and monitoring, and mutual help-group promotion. Although existing research provides implications for implementing EBIs in continuing care, few direct implementation trials have been conducted. This literature indicates that EBIs in continuing care have been successfully modified for different settings, that they can be delivered using different modalities (e.g., individual, group, and telephone-based care), and that low cost options are available. Additionally, much is known about the differential effectiveness of continuing care with different populations that may guide treatment programs and providers in selecting the most effective interventions for their clients. One significant barrier to successful implementation of EBIs for continuing care is the lack of information about incentives for providing continuing care across what in the CFIR terminology is a program's outer setting (i.e., external economic, political, and social setting), and its inner setting (i.e., internal political, structural, and cultural contexts). Implications for implementation of EBIs in substance use disorder continuing care are discussed.

Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment.

Epidemiological data from treatment and community samples of individuals with substance use disorders indicate that the rates of co-occurring psychiatric disorders are high and that these disorders are associated with poor treatment adherence and outcomes. A growing body of research indicates that continuing care adherence interventions positively impact treatment outcome. However, it is unclear whether these interventions are effective for individuals with co-occurring psychiatric disorders. This paper explores this question with data from 150 participants who were randomized to receive a behavioral continuing care adherence intervention involving contracting, prompting and reinforcing attendance (CPR), or standard treatment. Fifty-one percent of the participants had one or more co-occurring Axis I or Axis II psychiatric disorders in addition to a SUD diagnosis. Among individuals with co-occurring disorders, those who received the CPR intervention show increased duration of treatment and improved 1-year abstinence rates compared to those who received STX. Additionally, effects of the CPR intervention were generally more pronounced among persons with co-occurring Axis I and/or Axis II disorders than those without these disorders. Treatment implications are discussed.

Contracting, prompting, and reinforcing substance use disorder continuing care: a randomized clinical trial.

Although continuing care is strongly related to positive treatment outcomes for substance use disorder (SUD), participation rates are low and few effective interventions are available. In a randomized clinical trial with 150 participants (97% men), 75 graduates of a residential Veterans Affairs Medical Center SUD program who received an aftercare contract, attendance prompts, and reinforcers (CPR) were compared to 75 graduates who received standard treatment (STX). Among CPR participants, 55% completed at least 3 months of aftercare, compared to 36% in STX. Similarly, CPR participants remained in treatment longer than those in STX (5.5 vs. 4.4 months). Additionally, CPR participants were more likely to be abstinent compared to STX (57% vs. 37%) after 1 year. The CPR intervention offers a practical means to improve adherence among individuals in SUD treatment.

Convergent validity of the Timeline Followback for persons with comorbid psychiatric disorders engaged in residential substance use treatment.

This study examined the convergent validity of the Timeline Followback (TLFB) for individuals with comorbid (Axis I and/or Axis II) psychiatric disorders in a sample of persons (N=150) engaged in residential treatment for substance use disorders (SUDs). Approximately one-half of the sample was diagnosed with at least one comorbid psychiatric disorder. Validity was assessed comparing data from the TLFB with data from the Addiction Severity Index (ASI) and collateral reports. For the entire sample, data from the TLFB was significantly correlated with data from the ASI and collateral reports of substance use. No significant differences were found between those with and those without a comorbid psychiatric disorder, suggesting that the TLFB was equally valid for both groups.

The impact of contracting and prompting substance abuse treatment entry: a pilot trial.

Contracting and prompting clients to attend substance abuse treatment aftercare substantially improves treatment adherence and outcome. However, this approach has not been evaluated for improving entry into initial treatment. We recruited 102 individuals scheduled to begin a 28-day substance use disorder (SUD) residential treatment program and randomly assigned them to receive either our standard treatment (STX) or STX plus attendance contracting and prompting (CP). CP participants showed fewer subsequent hospitalization days, lower hospitalization costs, greater improvement in alcohol problem scores, and lower legal problem scores at a 3-month follow-up than the STX group. The two groups did not differ on treatment entry rate, time in treatment, or drug use problem scores. The clinical utility of CP procedures and areas for future research are discussed.