This application addresses broad Challenge Area (05) Comparative Effectiveness Research and specific Challenge Topic, 05-DA-105* Comparing Episodic and Continuous Care for Drug Abuse Treatment. Drug addiction is a chronic illness often characterized by periods of problematic drug use, reductions in use, abstinence, and relapse to problematic drug use. Despite this, substance abuse treatment has traditionally been based on an acute care model-a model that is not sensitive to the long-term nature of the disorder. Aftercare and continuing care models have been developed to extend the benefits of the initial treatment episode, and recovery monitoring has been developed to assess patients'status and return them to treatment as needed. While important advances, limitations of these models include: 1) their narrow focus on treatment completers;2) their general inability to adjust to changes in patient status;3) patients tiring of participation and dropping out;and 4) the treatment is of limited duration. Recommendations for improving continuing care interventions include: 1) engaging patients earlier in the treatment process;2) reducing the burden of treatment for participants;3) developing algorithms that adjust the treatment to the patient's response;and 4) utilizing active outreach to engage and retain patients. The field needs an addiction management model for drug-dependent patients, which, like disease management for other chronic conditions, provides: 1) initial stabilization;2) ongoing treatment to maintain clinical gains;3) monitoring of patient symptoms;and 4) adjustments to the treatment based on the patient's response. The latter component is to help ensure adequate intervention with the minimum burden to the patient. In response to these needs we have developed the Long-Term Recovery Management (LTRM) model. LTRM is predicated on initiating long-term addiction management at the onset of treatment, extending the length of treatment, expediting the transitions between intensive treatment and maintenance of behavioral change, adapting treatment intensity to patient's response to treatment, and actively facilitating the therapeutic alliance. Using techniques from several behavioral therapies (Community Reinforcement Approach (CRA), Contingency Management (CM), and Facilitated Therapeutic Alliance (FTA)) with demonstrated efficacy, the LTRM model emphasizes: engagement in continuous care and recovery support, therapeutic alliance, and early re-intervention as the main mechanisms for the maintenance of behavioral change. The purpose of this study is to conduct a fully powered effectiveness trial comparing the recovery trajectories of 200 drug dependent adults who are randomly assigned to Treatment as Usual (TAU) or LTRM. This research will be conducted in an outpatient, community-based treatment program in Columbus, Ohio. Patients will be engaged in LTRM during the first 2 weeks of entry into outpatient treatment and continue for 12 months, with research assessments conducted at 6 and 12 months after baseline. The main outcome variable is weeks of abstinence from primary drug of dependence. Secondary outcomes include drug-free days and reductions in HIV risk behaviors.
The Aims and Hypotheses are:
Specific Aim 1. To compare the effectiveness of an episodic care model (TAU) and a continuous care model (LTRM) of substance abuse treatment among drug dependent adults. Hypothesis 1: Participants in LTRM will have better abstinence outcomes for their primary drug of dependence, compared to those in TAU. Hypothesis 2: Participants in the Long-Term Recovery Management (LTRM) condition will have a larger number of drug-free days, including alcohol, compared to those in the treatment as usual (TAU) condition. Secondary Aim 1. To compare HIV risk behaviors among participants in LTRM versus TAU. Hypothesis 3. Participants in LTRM will have fewer HIV risk behaviors, compared to participants in TAU. Exploratory Aim 1. To identify key moderating factors, such as primary drug of dependence, gender, ethnicity, and psychiatric comorbidity, that may influence treatment outcome. The proposed study is significant because it will add important perspective to findings from previous randomized trials oriented to chronic disease management that have largely focused on either """"""""recovery monitoring"""""""" and re-engagement with stepped-up services when indicated or, clinic- or telephone-based continuing care interventions. In contrast with these important advances, LTRM engages all clients within 2 weeks of outpatient treatment engagement. The study is innovative because the LTRM experimental intervention combines 3 established treatment techniques (CRA, CM, and FTA), each with demonstrated efficacy, into a chronic disease treatment model. In addition, patient cases will be kept open, thereby removing potential obstacles to re-engagement with stepped-up care, when indicated. The proposed study is a clinical effectiveness trial in which 200 drug-dependent, adult outpatients from a community treatment center will be randomly assigned to Treatment as Usual or a newly developed, long-term treatment, referred to as """"""""Long-Term Recovery Management."""""""" The results will benefit public health by adapting treatment and recovery services to the chronic nature of addiction.
The proposed study is a clinical effectiveness trial in which 200 drug-dependent, adult outpatients from a community treatment center will be randomly assigned to Treatment as Usual or a newly developed, long-term treatment, referred to as Long-Term Recovery Management. The results will benefit public health by adapting treatment and recovery services to the chronic nature of addiction.