Substance use disorders (SUD) are a substantial problem among Veterans, with evidence indicating recent increases, particularly among OEF/OIF Veterans. Despite the recent development and dissemination of clinical practice guidelines for the use of evidence-based treatments, such treatments may still lead to less than optimal engagement and retention. 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) system offer characteristics such as low cost, consistent delivery, and convenience and have been shown to improve clinical outcomes in several chronic disorders. We recently developed the Recovery Line, a CBT-based IVR system demonstrated to reduce substance use in patients in methadone treatment. However, methadone is a significantly different treatment context than SUD treatment in VHA. Thus, it is important to evaluate its feasibility and acceptability in a VHA SUD treatment setting.
Objective 1: To evaluate feasibility and acceptability of the Veterans' Recovery Line among Veteran patients. Objective 2: To evaluate feasibility and acceptability of the Veterans' Recovery Line among providers and clinic staff.
Objective 3: To evaluate initial efficacy of the Veterans' Recovery Line among patients starting substance abuse treatment.
This study was a mixed methods evaluation of the feasibility, acceptability and preliminary efficacy of the Veterans' Recovery Line (VRL) as an ancillary intervention in substance abuse treatment. Veteran patients (N=35) in the Substance Abuse Day Program were recruited over 7.5 months for a 5-week randomized pilot trial. Patients were randomly assigned to receive treatment-as-usual (TAU, n=15) or to receive the Veterans' Recovery Line plus TAU (VRL+TAU, n=20). Primary outcome measures were retention and attendance in care. Additional feasibility and preliminary efficacy data included participation of eligible patients, number of system calls, days/week of primary substance use, days/week of any substance use, and coping skills efficacy. Patient and staff qualitative data on system acceptability, effectiveness, and barriers and facilitators were also collected. A specified apriori criteria was used to evaluate whether a full scale effectiveness trial would be warranted.
There were no differences between groups on any demographic or baseline substance use characteristics. SADP treatment completion was high (86%, n=30) and did not differ by condition (p=.40).
Findings met the apriori criteria of acceptability and feasibility for a full scale trial. First, the majority (73%) of eligible patients participated in the study, and none refused their assigned condition. Second, findings indicated that the VRL improved treatment acceptability of the SADP treatment. Patients assigned to the VRL+TAU had marginally more days in treatment after their randomization date (9.2vs.5.9, p=.055), attended more SADP sessions than those assigned to TAU only (54.7 vs. 46.0, p=.03). Third, VRL use met the acceptability criteria (>50% calling >5 days for >30 minutes; M=13.4 calls, and M=122 minutes). Finally, findings suggest that the VRL improved treatment outcome. Although self-reported primary and any substance use days/week decreased dramatically and did not differ by condition (p's>.27), coping skills efficacy (ECBI) improved significantly for VRL+TAU (19.6 to 30.3, p=.001), but not for TAU only (p=.54; p=.01 for the interaction).
In semi-structured qualitative interviews SADP providers (n=4) reported positive feedback from patients about the VRL and instances in which patients discussed, in treatment groups or one-on-one meetings, that the VRL supported their recovery. Providers were optimistic about the integration of the VRL into SADP and felt the VRL was a useful extension of their SADP program when patients could not access their clinician.
The promising findings from this pilot 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 VHA. The pilot also provides a successful template for adapting telehealth technologies and includes methodological innovations (e.g., specification of apriori acceptability and feasibility criteria).
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