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IIR 07-264 – HSR&D Study

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IIR 07-264
Treating Violence-Prone Substance Use Disorder Patients
Christine Timko PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: September 2008 - August 2012

BACKGROUND/RATIONALE:
Interpersonal violence (IPV) among substance use disorder (SUD) patients is common, undertreated, and costly. SUD patients have high rates of perpetrating IPV, and IPV is a risk factor for poor response to SUD treatment. Failure to address IPV among SUD patients interferes with treatment effectiveness and contributes to relapse and higher rates of health services use. Nonetheless, SUD treatment programs typically do not include violence prevention interventions and few studies have examined interventions designed to prevent violence perpetration among SUD patients.

OBJECTIVE(S):
This trial evaluated the effectiveness of an IPV-prevention (IPV-P) intervention among patients entering VA SUD treatment who had perpetrated violence in the past year against another adult. Primary objectives were to test the hypotheses that, compared to patients assigned to a control condition (CC), those assigned to IPV-P would (1) improve more on violence and SUD outcomes, and (2) use fewer VA mental health and medical care services, thereby saving costs for VA. Secondary objectives were to test the hypothesis that, compared to patients assigned to CC, those assigned to IPV-P would improve more on legal and alienation problems and social resources.

METHODS:
Patients entering VA SUD treatment who met eligibility criteria (past-year violence; cognitively intact) and provided informed consent were assigned to SUD usual care plus either a CC (N=60) or IPV-P (N=59) intervention using a recurrent institutional design. That is, the IPV-P and CC conditions were run in alternate 3-month periods. The manualized IPV-P group intervention, based on a Cognitive-Behavioral approach, consisted of 8 in-person group sessions over 1 month, followed by telephone calls once a month for 3 months. The manualized CC was designed to control for non-specific treatment effects associated with the IPV-P condition, i.e., counselor time and attention, peer support, patients' expectations that additional sessions provide benefit. It consisted of 8 in-person group sessions over 1 month that reviewed material covered in usual SUD treatment, but with novel methods used to deliver the IPV-P intervention (role-play, homework, group activities). CC included the booster telephone sessions (once per month for 3 months). Participants were assessed at baseline and end-of-intervention (4 months post-baseline) and 6 and 12 months post-intervention (i.e., 10 and 16 months post-baseline) for primary and secondary outcomes and non-VA healthcare. Assessments consisted of the Addiction Severity Index (ASI, to assess Alcohol, Drugs, Psychiatric, and Legal functioning), the Conflicts Tactics Scale (CTS, to assess Psychological Aggression and Physical Assault against another adult), the Multidimensional Personality Questionnaire (MDQ, to assess Alienation, Stress Reaction, and Aggression), and the Life Stressors and Social Resources Inventory (LISRES, to assess family and friends resources). VA health care is being assessed with VA databases. Response rates at 4, 10, and 16 months were 90%, 79%, and 73%, respectively, and did not differ between the IPV-P and CC groups. Follow-up analyses compared the IPV-P to the CC group on outcomes using analyses of covariance that controlled for the baseline value of the outcome.

FINDINGS/RESULTS:
Sample. Baseline characteristics (demographics and all other measures) did not differ between participants assigned to IPV-P or CC. The sample was 94.3% male and 47.5% White, and had a mean age of 51.1 years old (SD=10.9), a mean of 13.4 (SD=2.0) years of education, and a mean of 4.6 (SD=8.4) days employed in the past month. Only 9.9% of the sample was married, and 13.5% were homeless. A surprisingly high proportion of patients (76.6%) reported past-30 day abstinence from alcohol and other drugs at baseline.

End-of-Intervention. At the 4-month follow-up, the two groups did not differ on ASI alcohol, drugs, or psychiatric composite scores when baseline values were controlled. However, the IPV-P group had lower scores, indicating better functioning, on the ASI legal composite (IPV-P group mean=.012, SD=.049; CC group mean=.038, SD=.049); F=3.60, p<.05). The two groups did not differ on the CTS's frequency of psychological aggression or physical assault over the previous 4 months. However, the IPV-P group scored significantly lower than the CC group on the MPQ's scales of Alienation (i.e., feels betrayed, deceived, exploited, mistreated; believes other wish him to fail, sees self as target of false rumors; IPV-P group mean=3.7, SD=3.3; CC group mean= 5.1, SD=3.3; F=6.76, p<.005), Stress Reaction (i.e., easily upset; sensitive, has unaccountable mood changes; IPV-P group mean=6.7, SD=3.4; CC group mean=8.0, SD=3.4; F=4.81, p<.05), and Aggression (enjoys distressing others, enjoys observing violence, physically violent, vengeful, vindictive, victimizes others for own gain; IPV-P group mean = 2.9, SD=3.0; CC group mean=3.9, SD=3.3; F=4.2, p<.05). In addition, the IPV-P group scored higher on the LISRES scales of family resources (IPV-P group mean=12.7, SD=6.9; CC group mean=7.6, SD=7.4; F=17.79, p<.000), and friends resources (IPV-P group mean=6.0, SD=3.4; CC group mean=4.1, SD=4.7; F=6.90, p<.005). Further, the IPV-P group was more satisfied with their treatment than was the CC group (F=3.02, p<.05).

10-month follow-up. At the 10-month follow-up, the two groups did not differ on ASI composite or CTS scores. The IPV-P group maintained better outcomes compared to the CC group by having lower Alienation scores (Means = 3.1 [SD=3.2] vs. 4.5 [SD=3.5]; F=6.01 (p<.01) and higher scores on family resources (Means = 8.3 [7.7] vs. 6.1 [7.7]; F=3.4, p<.05) and friends resources (Means = 10.8 [SD=8.5] vs. 7.1 [SD=7.9]; F=7.44, p<.005).

16-month follow-up. At the 16-month follow-up, the two groups did not differ on ASI composite scores. The IPV-P group was less likely than the CC group to have been psychologically aggressive toward another adult (43.2% vs. 59.7%; F=2.7, p<.05), and continued to report less Alienation (Means=3.2 (SD=3.6) vs. 4.3 [SD=3.7]; F=3.27, p<.05). The IPV-P group also continued to have more family (Means = 12.3 [SD =7.6 ] vs. 9.3 [SD=6.9]; F=6.63, p<.01) and friends (Means = 12.9 [SD =7.1 ] vs. 10.6 [SD=7.3]; F=3.12, p<.04) resources.

IMPACT:
This sample, despite entering SUD treatment, had already achieved past 30-day abstinence at a high rate. In addition, our test of IPV-P was quite conservative, because instead of using usual care as a comparison, the comparison condition was enhanced usual care. Thus it is not surprising that the intervention and control groups did not differ on alcohol and drug use severity indices at follow-ups. Even with a largely-abstinent sample, and a comparison of IPV-P to enhanced usual care, we found that the violence-prevention intervention was associated with decreased legal problems (4 months), stress reactions (4 months), feelings of alienation (4 and 10 months), and aggression (4 and 16 months), and increased family and friend resources (4, 10, and 16 months). It was also associated with increased treatment satisfaction. These results suggest that the violence-prevention intervention was successful at helping Veterans change the thoughts and behaviors associated with the perpetration of violence and its negative consequences to self and others. Possibly, implementation of the intervention in VA SUD programs would show comparable benefits.

PUBLICATIONS:

Journal Articles

  1. Blonigen DM, Timko C, Moos BS, Moos RH. Impulsivity is an independent predictor of 15-year mortality risk among individuals seeking help for alcohol-related problems. Alcoholism, clinical and experimental research. 2011 Nov 1; 35(11):2082-92.
  2. Timko C, Sutkowi A, Cronkite RC, Makin-Byrd K, Moos RH. Intensive referral to 12-step dual-focused mutual-help groups. Drug and Alcohol Dependence. 2011 Nov 1; 118(2-3):194-201.
  3. Makin-Byrd K, Cronkite RC, Timko C. The influence of abuse victimization on attendance and involvement in mutual-help groups among dually diagnosed male veterans. Journal of substance abuse treatment. 2011 Jul 1; 41(1):78-87.
  4. Timko C, Desai A, Blonigen DM, Moos BS, Moos RH. Driving while intoxicated among individuals initially untreated for alcohol use disorders: one- and sixteen-year follow-ups. Journal of studies on alcohol and drugs. 2011 Mar 1; 72(2):173-84.
Conference Presentations

  1. Heinz AJ, Schultz N, Makin-Byrd K, Blonigen DM, Timko C. Posttraumatic stress, impulsivity, and aggressive behavior among substance use disorder treatment patients. Poster session presented at: Association for Psychological Science Annual Convention; 2014 May 23; San Francisco, CA.
  2. Blonigen DM, Timko C, Moos BS, Moos RH. Impulsivity is an independent predictor of 15-year mortality risk among individuals seeking help for an alcohol use disorder. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2010 Nov 21; San Francisco, CA.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
DRE: Diagnosis, Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Addictive Disorders, Substance Use and Abuse
MeSH Terms: none