Abstract:

There is considerable evidence that treatment for alcohol disorders can lead to significant improvements in substance use and psychosocial problem severity. However, many patients relapse to heavy drinking after primary treatment. Patients are therefore frequently referred to continuing care programs to prevent relapse and decrease the probability of additional rehabilitation treatments. Findings suggest that current models of continuing care may not be adequate for the long-term management of a chronic, relapsing disorder such as alcoholism. One possible approach for improving the long-term management of alcoholism is low intensity monitoring and counseling, with the provision to increase the intensity of treatment when warranted.

Alcohol dependent patients who have completed 3 weeks of intensive outpatient treatment will be randomly assigned to one of the following interventions: (1) continued participation instandard outpatient treatment without additional intervention (TAU); (2) TAU plus brief monitoring and feedback via telephone on a tapered schedule out to 18 months (TMF); or (3) TAU plus brief monitoring and counseling via telephone on a tapered schedule out to 18 months (TMC). The TMC condition will also include an “adaptive” component, in which intensity of treatment can be increased when specified criteria have been met. The inclusion of the TMF condition will make it possible to determine whether simply monitoring with minimal feedback, without counseling and adaptive provisions, is sufficient to maintain good outcomes. In addition, patients in TMC and TMF will also be randomized a second time to either receive or not receive active efforts to enlist a “recovery facilitator” (i.e., friend, spouse, self-help group member) to provide extra support when needed.

Patients will be followed at 3, 6, 9, 12, 15, 18, 21, and 24 months post intake into the study. Follow-up assessments will include measures of drinking and drug use, treatment process and potential mediating factors (e.g., motivation, therapeutic alliance, self-efficacy, mood, social support, self-help involvement, housing), psychosocial problem severity, and utilization of health and social services. TMF and TMC are predicted to produce better alcohol use outcomes than TAU, with an advantage of TMC over TMF emerging later in the follow-up. Other analyses will examine mediating and moderating factors. Economic analyses will determine the cost-effectiveness and benefit-cost of TMC and TMF relative to TAU, and each other.

Specific Aims:

Primary Objective 1: To evaluate the efficacy of extended (i.e., 18 month) telephone monitoring and counseling (TMC) over a 24-month follow-up, as compared to extended telephone monitoring and feedback only (TMF), and to treatment as usual without adjunctive telephone contacts (TAU), for alcohol dependent patients in a community-based clinic.

• Hypothesis 1: The extended telephone monitoring conditions (TMC and TMF) will produce better alcohol use outcomes than TAU.

• Hypothesis 2: There will be a group by time interaction in which a treatment effect favoring TMC over TMF on alcohol use outcomes will emerge as the follow-up progresses.

• Hypothesis 3: Patients who receive active efforts to enlist a “recovery facilitator” to provide help and support when needed will have better alcohol use outcomes than those who do not receive these active efforts.

Primary Objective 2: To test hypotheses concerning treatment process measures and examine potential mediational effects that contribute to alcohol use outcomes. Prior alcohol research has indicated that a number of process measures, including therapeutic alliance, self-help attendance, commitment to abstinence, readiness to change, self-efficacy, mood, and social support, predict subsequent drinking outcomes. In the present study, the extended contactprovided by the telephone conditions is expected to sustain better scores on these measures. A formal analysis of the potential mediating effects of these variables will also be conducted as. These analyses will determine to what extent treatment effects are mediated by change on these variables.

• Hypothesis 4: Higher scores on measures of therapeutic alliance, self-help attendance, commitment to abstinence, readiness to change, self-efficacy, positive mood, and social support assessed at each follow-up point will predict better alcohol outcomes at subsequent follow-ups.

• Hypothesis 5: There will be main effects for treatment condition on these measures, with scores highest in TMC, followed by TMF, and TAU.

• Hypothesis 6: The treatment effects in hypotheses 1, 2, and 3 will be partially mediated by these treatment process measures.

Primary objective 3: To evaluate the economic impact of TMC and TMF, relative to each other and TAU.

• Economic hypothesis 1: The extended telephone conditions (TMC and TMF) will be more cost-effective than TAU.

• Economic hypothesis 2: The extended telephone conditions (TMC and TMF) will show greater net benefits than TAU.

Secondary objective: To identify variables that predict differential response to the three treatment conditions. Although we are hypothesizing a main effect favoring the TMC and TMF conditions over TAU, it is possible that certain patients are particularly in need of long-term monitoring. This could include patients with histories of multiple treatment episodes coupled with failure to engage in self-help programs, those that have very limited or nonexistent social support, or those who are doing poorly in the first month of treatment. Because these analyses are exploratory, this objective is considered secondary.