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Intervention Summary

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Contracts, Prompts, and Reinforcement of Substance Use Disorder Continuing Care (CPR)

Contracts, Prompts, and Reinforcement of Substance Use Disorder Continuing Care (CPR) is an aftercare intervention for adults that begins in the final week of residential substance abuse treatment. CPR aims to help clients after discharge to participate in aftercare treatment (individual and group therapy) and self-help support groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), maintain alcohol and drug abstinence, and reduce the problems they have experienced as a result of their substance use. Based on a cognitive-behavioral model, CPR uses aftercare contracts, written and telephone reminder prompts, and a series of social reinforcers, such as letters, certificates, and medallions. Although the intervention is not gender specific and has been used in multiple settings, the study reviewed in this summary was conducted with predominantly male clients in a Department of Veterans Affairs (VA) medical center.

CPR begins with a written aftercare contract between the therapist and client established during the final week of residential substance abuse treatment. The contract outlines a commitment to participate in weekly group therapy and AA/NA meetings as well as monthly individual therapy for at least 8 weeks after discharge from the treatment program. Recontracting occurs after 8 weeks to reinforce continuing aftercare treatment and AA/NA participation for the next 9 months. Throughout aftercare, CPR clients receive personal letters, appointment cards, and automated telephone reminder prompts to facilitate their attendance at therapy sessions and AA/NA meetings, and written and phone follow-ups let them know when they have missed sessions. Using principles of contingency management, CPR also provides clients with social reinforcers in the form of handwritten congratulatory letters for aftercare attendance, a certificate 90 days after entry into residential substance abuse treatment, a medallion after 3 months of aftercare, and a certificate and medallion 1 year after entry into residential treatment. These reinforcers are given during regularly scheduled therapy sessions. Both the full CPR intervention and its individual components (aftercare contracting, attendance prompts, and social reinforcement) have been used with clients following discharge from residential substance abuse treatment.

Descriptive Information

Areas of Interest Substance abuse treatment
Co-occurring disorders
Outcomes Review Date: February 2010
1: Participation in aftercare treatment and self-help groups
2: Substance abstinence
3: Substance use-related problems
Outcome Categories Alcohol
Crime/delinquency
Drugs
Employment
Family/relationships
Treatment/recovery
Ages 26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Settings Residential
Outpatient
Other community settings
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History CPR was developed and tested in a stepwise fashion between 1994 and 1999, with the full intervention first implemented in 1998. Since 1999, approximately 30 sites across 25 States have implemented the full CPR intervention. At the 2 primary sites where it was developed, the intervention has reached approximately 1,700 clients.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: February 2010

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

DeMarce, J. M., Lash, S. J., Stephens, R. S., Grambow, S. C., & Burden, J. L. (2008). Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment. Addictive Behaviors, 33(9), 1104-1112.  Pub Med icon

Lash, S. J., Stephens, R. S., Burden, J. L., Grambow, S. C., DeMarce, J. M., Jones, M. E., et al. (2007). Contracting, prompting, and reinforcing substance use disorder continuing care: A randomized clinical trial. Psychology of Addictive Behaviors, 21(3), 387-397.  Pub Med icon

Supplementary Materials

Agrawal, S., Sobell, M. B., & Sobell, L. C. (2008). The Timeline Followback: A scientifically and clinically useful tool for assessing substance use. In R. F. Belli, F. P. Stafford, & D. F. Alwin (Eds.), Calendar and time diary methods in life course research (pp. 57-68). Washington, DC: Sage.

CPR fidelity protocol checklists and samples of letter and telephone follow-up prompts

DeMarce, J. M., Burden, J. L., Lash, S. J., Stephens, R. S., & Grambow, S. C. (2007). Convergent validity of the Timeline Followback for persons with comorbid psychiatric disorders engaged in residential substance use treatment. Addictive Behaviors, 32(8), 1582-1592.  Pub Med icon

Lash, S. J., Burden, J. L., Monteleone, B. R., & Lehmann, L. P. (2004). Social reinforcement of substance abuse treatment aftercare participation: Impact on outcome. Addictive Behaviors, 29(2), 337-342.  Pub Med icon

Lash, S. J., Petersen, G. E., O'Connor, E. A., Jr., & Lehmann, L. P. (2001). Social reinforcement of substance abuse aftercare group therapy attendance. Journal of Substance Abuse Treatment, 20(1), 3-8.  Pub Med icon

McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., et al. (1992). The Fifth Edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9(3), 199-213.  Pub Med icon

Tonigan, J. S., Miller, W. R., & Brown, J. M. (1997). The reliability of Form 90: An instrument for assessing alcohol treatment outcome. Journal of Studies on Alcohol, 58(4), 358-364.  Pub Med icon

Outcomes

Outcome 1: Participation in aftercare treatment and self-help groups
Description of Measures Participation in aftercare treatment was measured as the number of months in which clients attended at least two aftercare sessions (individual or group therapy) as recorded in their medical records.

Participation in self-help groups was measured as the number of AA and NA self-help group meetings attended per month as reported using the Form-90 Interview (Form 90I). This instrument is a structured interview that uses a calendar-based method for assisting in the self-report of daily substance use and related behaviors during the prior 90 days. Assessments occurred at baseline (3 weeks after entry into residential treatment) and 3, 6, and 12 months after entry into residential treatment.
Key Findings In a randomized clinical trial, graduates of a 28-day residential substance abuse treatment program at a VA medical center were assigned to one of two aftercare conditions during the final week of treatment: usual care (a standard aftercare orientation session) or usual care plus CPR. Findings from this study included the following:

  • A higher percentage of CPR than usual care clients began aftercare treatment (94.7% vs. 82.7%; p = .02), completed at least 2 months of aftercare treatment (74.7% vs. 45.3%; p < .01), and completed at least 3 months of aftercare treatment (55% vs. 36%; p = .02). However, for both groups, the percentage of clients attending at least two aftercare therapy sessions per month gradually decreased across the 12 months of follow-up (p < .01).
  • Among clients with co-occurring psychiatric and substance use disorders, a higher percentage of CPR than usual care clients began aftercare treatment (93.2% vs. 72.7%; p = .01) and completed at least 2 months of aftercare treatment (68.2% vs. 24.2%; p = .0001). The effect sizes for these group differences were medium (odds ratio = 5.13) and large (odds ratio = 6.70), respectively.
  • CPR clients most frequently reported 4.0 months of aftercare treatment, compared with 3.0 months reported by usual care clients (p = .02).
  • Although CPR clients reported more monthly AA/NA meetings attended during the follow-up period compared with baseline (p < .01), there was no group difference between CPR and usual care clients in reported monthly AA/NA meetings attended during the follow-up period.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 2: Substance abstinence
Description of Measures Substance abstinence was measured by Form 90I, a structured interview that uses a calendar-based method for assisting in the self-report of daily substance use and related behaviors over the prior 90 days. Self-reported abstinence on Form 90I was verified by a collateral report using a collateral interview version of Form 90I, self-reported substance use using the Addiction Severity Index (ASI), urinalysis, and a measure of breath alcohol content (BAC) using a portable breathalyzer. The ASI is a semistructured interview that measures types and severity of problems in seven domains: medical, employment, alcohol use, drug use, legal status, family relations, and psychiatric functioning. Assessments occurred at baseline (3 weeks after entry into residential treatment) and 3, 6, and 12 months after entry into residential treatment.
Key Findings In a randomized clinical trial, graduates of a 28-day residential substance abuse treatment program at a VA medical center were assigned to one of two aftercare conditions during the final week of treatment: usual care (a standard aftercare orientation session) or usual care plus CPR. Findings from this study included the following:

  • A higher percentage of CPR than usual care clients reported at the 12-month follow-up that they had been abstinent for the prior 90-day period (56.9% vs. 37.3%; p = .03).
  • Among clients with co-occurring psychiatric and substance use disorders, CPR clients were more likely than their usual care counterparts to report at the 12-month follow-up that they had been abstinent for the prior 90-day period (50% vs. 21.2%; p = .01). This group difference was associated with a medium effect size (odds ratio = 3.71).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 3: Substance use-related problems
Description of Measures Substance use-related problems were measured using the ASI, a semistructured interview that measures the types and severity of problems in seven domains: medical, employment, alcohol use, drug use, legal status, family relations, and psychiatric functioning. Assessments occurred at baseline (3 weeks after entry into residential treatment) and 3, 6, and 12 months after entry into residential treatment.
Key Findings In a randomized clinical trial, graduates of a 28-day residential substance abuse treatment program at a VA medical center were assigned to one of two aftercare conditions during the final week of treatment: usual care (a standard aftercare orientation session) or usual care plus CPR. Findings from this study included the following:

  • CPR clients had a larger reduction in self-reported alcohol-related problems (ASI composite problem score) than usual care clients from baseline to the 3-month follow-up (p = .024) but not from baseline to the 6- or 12-month follow-up.
  • Clients in both conditions had decreases in self-reported problem severity (ASI composite problem scores) associated with alcohol use (p < .01), drug use (p < .01), employment (p < .01), family relations (p < .01), and legal status (p = .03) across the 12 months of follow-up.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult)
55+ (Older adult)
96.7% Male
3.3% Female
53.3% Black or African American
45.3% White
1.3% Hispanic or Latino

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Participation in aftercare treatment and self-help groups 3.5 3.5 3.0 3.5 4.0 3.2 3.4
2: Substance abstinence 4.0 4.0 3.0 3.5 4.0 3.2 3.6
3: Substance use-related problems 4.0 4.0 3.0 3.5 4.0 2.5 3.5

Study Strengths

The measure of participation in aftercare treatment, based on data from medical records, was easily validated. Drug and alcohol abstinence was measured by a self-report instrument with strong psychometric properties (Form 90I), with results verified by collateral reports, measures of BAC, and urinalysis. Assessments were carried out by trained graduate students blind to treatment condition. CPR therapists followed a manual and general scripts for telephone prompts, with ongoing supervision throughout the study. The study design included random assignment to conditions and an adequate sample size to ensure statistical power to detect outcome differences between conditions. Outcome findings were consistent across the multiple statistical approaches used to address missing data and client attrition.

Study Weaknesses

About half the scheduled prompting phone calls were not conducted. No tested fidelity instrument was used. For the subgroup of participants with a co-occurring psychiatric diagnosis, logistic regression would have been more appropriate than multiple chi-square tests to determine condition differences in the outcomes.

Readiness for Dissemination
Review Date: February 2010

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Lash, S. J., Burden, J. L., & Parker, J. D. (2009). Contracts, Prompts and Reinforcement (CPR) contracting scripts. Salem, VA: Veterans Affairs Medical Center.

Lash, S. J., Burden, J. L., & Parker, J. D. (2009). Contracts, Prompts and Reinforcement (CPR) of substance abuse continuing care adherence and abstinence: A treatment manual. Salem, VA: Veterans Affairs Medical Center.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.4 3.0 3.9 3.4

Dissemination Strengths

The treatment manual provides detailed, coherent descriptions of each program component, along with well-designed scripts for therapists to use. Specific information on selecting clients and implementing the intervention as an adjunct to an existing therapeutic program is provided. Training and support for implementation are available from the developer. Tools and protocols for measuring outcomes, along with specific guidance for ongoing supervision, support quality assurance.

Dissemination Weaknesses

Little guidance is provided on how to adapt this intervention for use with specific cultural or ethnic groups. Some Web-based implementation materials are not readily accessible to all implementers. The implementation materials include a few typographical errors. No formalized training curriculum is available. Little support is provided for integrating quality assurance procedures with existing organizational processes.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Treatment manual and other intervention materials Free Yes
2-day, on-site training
  • For VA medical centers, trainer travel expenses only
  • For non-VA sites, $7,000 per site plus travel expenses
Yes
Ongoing supervision
  • For VA medical centers, trainer travel expenses only
  • For non-VA sites, $100 per hour
No
CPR database Free No
Supervisor rating forms Free No
Contact Information

To learn more about implementation or research, contact:
Steven J. Lash, Ph.D.
(540) 982-2463 ext 2593
Steven.Lash@va.gov

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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