Spotlight on Substance Use Disorder: Abstinence Reinforcement Therapy (ART) for Rural Veteran Smokers
Substance use disorder (SUD) is a disease that affects a person's brain and actions and eventually brings about an inability to control the use of a drug or medication despite impairment in work, school, or home life1. SUDs include dependencies on alcohol, illegal and prescription drugs, and nicotine2. A National Institute on Alcohol Abuse and Alcoholism (NIAAA) study found that approximately 4% of Americans met criteria for substance abuse disorder in the past year, and about 10% had a drug use disorder at one point in their lives. Based on these findings, NIAAA Director George F. Koob, PhD, estimated that 23 million Americans have struggled with problematic substance abuse3. The National Institutes of Health (NIH) estimates that abuse of tobacco, alcohol, and illicit drugs costs Americans more than $740 billion annually in crime, lost work productivity and health care4.
Among Veterans, approximately 11% of those presenting for first time care at VA meet diagnostic criteria for SUD, with higher prevalence among males, unmarried, and younger Veterans5. Almost 20% of Veterans returning from Iraq and Afghanistan suffer from PTSD, depression or traumatic brain injury which predispose one to substance abuse6. In fact, nearly one third of Veterans seeking treatment for SUD also have PTSD7. SUDs have substantial negative consequences on Veterans' mental and physical health, work performance, housing status, and ability to function socially.
VA has a history of treatment accomplishments in SUD including documentation of a link between smoking and lung cancer by 1940, development of the nicotine patch, leading early trials of the effectiveness of methadone, finding that HIV-positive Veterans with alcohol problems suffered more severe HIV-related symptoms, and development of a vaccine for methamphetamine addiction and testing it in mice8. VA continues to seek innovative and effective treatment for SUD.
Following are examples of HSR&D studies seeking to improve care and outcomes for Veterans living with SUDs.
Cigarette smoking is the most lethal substance use disorder in the United States in terms of morbidity and mortality and Veterans living in rural areas are at particularly high risk. Rural Veterans are significantly less likely to access intensive clinic-based smoking cessation care, so efforts are needed to expand the reach of smoking cessation treatment options beyond the clinic. The use of intensive behavioral therapies, such as contingency management (CM), may be a useful component to increase the efficacy of smoking cessation interventions. CM has shown efficacy for reducing smoking in several difficult-to-treat populations. Recent developments in mobile health (mHealth) have made CM more portable and feasible.
In this randomized controlled trial (RCT), 310 Veteran smokers were randomized to receive Abstinence Reinforcement Therapy (ART), which combined five sessions of proactive cognitive-behavioral telephone counseling (TC), a tele-medicine clinic for access to nicotine replacement (NRT), and mobile contingency management (mCM), or to a control group which received the same proactive counseling and tele-medicine clinic as ART but did not include mCM. In order to verify smoking abstinence, participating Veterans randomized to ART used a mobile device and app to video themselves blowing into a carbon monoxide monitor. They could receive up to $250 in incentives for complete abstinence during the 4-week CM intervention. Both groups were surveyed at 3 months, 6 months, and 12 months post-randomization for self-reported and biochemically validated measures of smoking abstinence.
- There were no statistically significant differences in smoking cessation by arm in 7-day self-reported abstinence at 3, 6, and 12 months.
- At the 12-month follow-up, 19% of veterans randomized to ART were bio-verified abstinent compared to 15% of the control group.
- ART was associated with significantly higher direct costs ($604 per patient) than the control arm ($164 per patient) which was largely due to costs associated with providing intervention participants mobile devices.
Impact: Quit rates, including 12-month prolonged abstinence and 12-month bio-verified abstinence, were high in both arms indicating support for a strategy that includes both proactive recruitment and proactive counseling paired with a tele-medicine clinic for access to NRT. Further, this project demonstrates that mobile monitoring and reinforcement of smoking abstinence in Veterans is feasible. The addition of relatively modest abstinence incentives, however, was not more effective at producing short or long-term abstinence than proactive counseling and NRT alone.
Principal Investigator: Patrick S. Calhoun, PhD, is a clinical psychologist and researcher at the Durham Center for Health Services Research in Primary Care; at the Durham VA Medical Center
This study resulted in the following publications:
Wilson SM, Hair LP, Hertzberg JS, Kirby AC, Olsen MK, Lindquist JH, Maciejewski ML, Beckham JC, Calhoun PS. Abstinence Reinforcement Therapy (ART) for rural veterans: Methodology for an mHealth smoking cessation intervention. Contemporary clinical trials. 2016 Sep 1; 50:157-65.
Despite the development and dissemination of clinical practice guidelines for the use of evidence-based treatment for substance use disorder (SUD), research suggests that less than optimal engagement and retention is still prevalent. Thus, there is a clear opportunity to develop acceptable and cost-effective ancillary substance abuse care to improve patient engagement, retention, and outcome. Therapeutic Interactive Voice Response (IVR) systems offer characteristics such as low cost, consistent delivery, and convenience, and have been shown to improve clinical outcomes in several chronic disorders. This study sought to evaluate the feasibility of implementing the Veterans Recovery Line (VRL), a cognitive behavioral therapy -based IVR system in a VHA SUD treatment setting.
- High rates of patient participation, call frequency, and call time support VRL’s feasibility and acceptability.
- The VRL improved treatment acceptability of the substance abuse day program (SADP) treatment.
- Compared to patients assigned to treatment-as-usual (TAU) only, patients assigned to VRL+TAU had more days in treatment after their randomization date (9 vs. 6), attended more SADP sessions (55 vs.46), and were less likely to receive intensive outpatient services following treatment (6% vs. 39%).
- Coping skills efficacy improved significantly for VRL+TAU but not for TAU only.
- Providers reported positive feedback from Veterans and felt the VRL was a useful extension of their SADP program when patients could not access their clinician.
Impact: The promising findings from this project indicate that a full-scale efficacy/effectiveness trial is warranted. The system is low-cost and scalable and if shown to be effective in a full trial could improve patient outcomes throughout VA.
Principal Investigator: Brent A. Moore is a Core Investigator at the HSR&D Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center at the VA Connecticut Healthcare System, West Haven, CT.
Publications resulting from this study are pending
Nicotine dependence is three to four times more common among individuals with a substance use disorder (SUD) than among individuals without SUD. Up to half of long-term smokers will die from smoking-related illness, making tobacco dependence (TD) the most lethal form of addiction. Despite this and VA policy and clinical practice guidelines specifying tobacco dependence treatment for all tobacco dependent Veterans in SUD treatment programs, tobacco dependence has historically not been a primary focus of treatment. Seventy-nine percent of patients in substance abuse residential rehabilitation treatment programs and domiciliaries (SARRTPs) are identified tobacco users, yet only 10% of tobacco-using patients receive both documented tobacco treatment and an ICD-9 tobacco dependence diagnosis. This study sought to implement and evaluate a multifaceted intervention program to increase tobacco treatment implementation in SARRTP programs at three VA sites.
Researchers used staff surveys, interviews, and stakeholder engagement meetings to tailor and refine a facilitation intervention model that had been successful in other VA mental health implementation efforts. The intervention was then evaluated to ascertain impact on tobacco use, continuity of care for tobacco-dependent Veterans, and implementation costs.
- Across all three sites providers expressed high knowledge of tobacco treatment and health effects but lower confidence in the efficacy of tobacco treatment and their ability to deliver treatment.
- Although Site 1 had limited leadership support, it underwent a cultural shift in the way staff addressed tobacco and showed significant improvement across all five survey scales (beliefs, knowledge, efficacy, practices, and barriers).
- At Site 2 there was far less penetration of tobacco practices to staff beyond the intervention champion team. It showed modest increases in most survey scales, but a decrease in the practice scale.
- Results from Site 3 and for the proportion of tobacco-using Veterans receiving pharmacotherapy during their residential stay are pending.
Impact: SUD residential treatment program staff have increased their knowledge of evidence-based tobacco treatment practices. The tobacco treatment dashboard, which was developed to provide audit and feedback to each site during the project, will ultimately be disseminated as a VA operations resource in collaboration with the Deputy Director of Mental Health Residential Rehabilitation Services in Mental Health Services. Monitoring of tobacco practices at all three sites continues, in order to understand whether the changes in tobacco treatment practices are sustainable beyond the lifetime of the project.
Principal Investigator: Elizabeth V Gifford, PhD, is a Research Health Science Specialist at the Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System, Palo Alto, CA
This study resulted in the following publications:
Gifford E, Tavakoli S, Wisdom J, Hamlett-Berry K. Implementation of smoking cessation treatment in VHA substance use disorder residential treatment programs. Psychiatric services (Washington, D.C.). 2015 Mar 1; 66(3):295-302.
TeleMonitoring to Improve Substance Use Disorder Treatment After Detoxification
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Every year, approximately 30,000 Veterans receive inpatient detoxification for substance use disorders (SUDs). Detoxification inpatients who enter SUD treatment and peer-based mutual-help groups (e.g., Alcoholics Anonymous) experience less substance use, homelessness, rehospitalizations and Emergency Department visits than those who do not. However, most Veterans discharged from detoxification do not enter SUD treatment, resulting in repeated detoxification admissions, with each episode potentially incurring higher risk of overdose.
This randomized trial at Palo Alto and Boston VA Medical Centers, sought to implement and evaluate Enhanced Telephone Monitoring (ETM) to facilitate the transition from inpatient detoxification to SUD specialty treatment. Veterans received an in-person session while in the detoxification program, followed by coaching over the telephone for 3 months after discharge. The intervention incorporated two facilitation approaches - Motivational Interviewing, and Contracting, Prompting, and Reinforcing - to facilitate entry into treatment and mutual-help groups, and thereby reduce the likelihood of another detoxification episode.
- At the 3-month follow-up ETM receiving Veterans were significantly less likely to have received additional inpatient detoxification, but no more likely to have participated in 12-step groups or received outpatient addiction treatment.
- ETM receiving Veterans did have better alcohol, drug, and mental health outcomes at the 3-month follow-up.
- At the 6-month follow-up (that is, 3 months after the intervention ended), patients in ETM and usual care (UC) generally did not differ on primary or secondary outcomes.
- Qualitative analyses of provider interviews found providers regarded the intervention as compatible with ongoing clinical practices.
Impact: This study demonstrates that telehealth interventions are a promising tool to help eradicate the dangerous, costly pattern of Veterans obtaining inpatient detoxification services but not receiving the follow-up they need. These findings will be useful in accomplishing the Office of Mental Health and Suicide Prevention (OMHSP)’s goal of implementing the Uniform Handbook, by suggesting a low-resource intervention that is feasible to use routinely to decrease repeated detoxifcations among Veterans.
Principal Investigator: Christine Timko PhD is a Senior Research Career Scientist at the Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System, Menlo Park, CA
This study resulted in the following publications:
Timko C, Below M, Vittorio L, Taylor E, Chang G, Lash S, Festin FED, Brief D. Randomized controlled trial of enhanced telephone monitoring with detoxification patients: 3- and 6-month outcomes. J Subst Abuse Treat. 2019 Apr;99:24-31. doi: 10.1016/j.jsat.2018.12.008. Epub 2019 Jan 4.