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IIR 20-067 – HSR&D Study

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IIR 20-067
Substance Abuse Self-Help Group Referral: Outcome and Services Use
Christine Timko PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: July 2002 - June 2005

BACKGROUND/RATIONALE:
Self-help groups (SHGs) have become an important component of the system of care for patients with substance use disorders (SUDs). SUD patients' participation in SHGs has been linked to lower relapse rates and less use of additional treatment services.

OBJECTIVE(S):
The first objective was to implement and validate procedures to help counselors make effective referrals to SHGs for SUD patients. This project randomly assigned SUD outpatients to a standard referral or an intensive referral condition. We are determining the extent to which intensive referral increased patients' SHG attendance and involvement in comparison to standard referral. The second objective is to determine whether patients who received intensive referral to SHGs have better substance use and functioning outcomes over the 1-year follow-up period, and less use of formal treatment services, thereby reducing costs for VA, than those who received standard referral. The long-term goal is to develop and implement guidelines to facilitate SUD patients' participation in SHGs and thereby improve their quality of life and decrease their use of VA's specialized SUD treatment services.

METHODS:
This project used a randomized design in which 345 patients entering VA outpatient SUD treatment were randomly assigned to either standard or intensive referral to SHGs. Standard referral consisted of the counselor recommending SHG participation. The keys to intensive referral included the counselor facilitating direct contact between the patient and a member of the SHG, and counselor follow-up on the recommendation for self-help. Patients were followed at 6 months and 1 year to determine whether intensive referral resulted in more self-help attendance and involvement; in better substance use and functioning outcomes (using the Addiction Severity Index); and in less use of VA services and lower treatment costs (using methods of the VA Health Economics Resource Center). To make these determinations, we are conducting analyses at each follow-up, and then will use hierarchical linear modeling to examine the benefits of intensive referral over time.

FINDINGS/RESULTS:
Among patients with relatively less previous SHG meeting attendance, intensive referral was associated with more SHG attendance during the 6-month follow-up than was standard referral. Among all patients, compared with those who received standard referral, patients who received intensive referral were more likely to be involved with SHGs during the 6-month follow-up (i.e., had done service, had a spiritual awakening, and currently had a sponsor). Intensive referral patients also had better alcohol and drug use outcomes at 6 months. SHG involvement mediated part of the association between referral condition and alcohol outcomes.

IMPACT:
This project is helping to specify clinical practices that enhance VA SUD patients' chances of recovery. The brief intensive referral intervention was associated with improved SHG involvement and substance use outcomes even among patients with considerable previous SHG exposure and formal treatment. Future intensive SHG referral procedures should focus on encouraging SHG involvement in addition to attendance to most benefit patients. The intensive referral procedures validated in this project should be efficient, inexpensive, and generalizable for use by SUD clinicians and primary care physicians in and outside the VA.

PUBLICATIONS:

Journal Articles

  1. Timko C, DeBenedetti A. A randomized controlled trial of intensive referral to 12-step self-help groups: one-year outcomes. Drug and Alcohol Dependence. 2007 Oct 8; 90(2-3):270-9.
  2. Timko C, Billow R, DeBenedetti A. Determinants of 12-step group affiliation and moderators of the affiliation-abstinence relationship. Drug and Alcohol Dependence. 2006 Jun 28; 83(2):111-21.
Conference Presentations

  1. Debenedetti A, Timko C. Veteran substance use disorder patients with fewer resources benefit more from 12-step groups. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  2. DeBenedetti AF, Moos RH, Timko C. Services for Dual Diagnosis Patients in the Psychiatric and Substance Abuse Systems. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD.


DRA: Substance Abuse and Addiction, Health Systems
DRE: Epidemiology
Keywords: Self-care
MeSH Terms: none